[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
THE ROLE OF THE INTERAGENCY PROGRAM OFFICE IN VA ELECTRONIC HEALTH
RECORD MODERNIZATION
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HEARING
BEFORE THE
SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
THURSDAY, SEPTEMBER 13, 2018
__________
Serial No. 115-78
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Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
35-832 PDF WASHINGTON : 2019
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COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BILL FLORES, Texas JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida CONOR LAMB, Pennsylvania
JODEY ARRINGTON, Texas ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
BRIAN MAST, Florida
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION
JIM BANKS, Indiana, Chairman
MIKE COFFMAN, Colorado CONOR LAMB, Pennsylvania, Ranking
JACK BERGMAN, Michigan Member
SCOTT PETERS, California
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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Thursday, September 13, 2018
Page
The Role Of The Interagency Program Office In VA Electronic
Health Record Modernization.................................... 1
OPENING STATEMENTS
Honorable Jim Banks, Chairman.................................... 1
Honorable Conor Lamb, Ranking Member............................. 3
WITNESSES
Dr. Lauren Thompson, Director, Interagency Program Office, U.S.
Department of Defense.......................................... 4
Prepared Statement........................................... 27
Accompanied by:
Dr. Helga Rippen, Deputy Director, Interagency Program
Office, U.S. Department of Veterans Affairs
John Windom, Acting Chief Health Information Officer and Program
Executive Officer, Office of Electronic Health Record
Modernization, U.S. Department of Veterans Affairs............. 5
Carol Harris, Director of IT Acquisition Management Issues, U.S.
Government Accountability Office............................... 7
Prepared Statement........................................... 29
THE ROLE OF THE INTERAGENCY PROGRAM OFFICE IN VA ELECTRONIC HEALTH
RECORD MODERNIZATION
----------
Thursday, September 13, 2018
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Technology Modernization
and Memorial Affairs,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 2:00 p.m., in
Room 334, Cannon House Office Building, Hon. Jim Banks
[Chairman of the Subcommittee] presiding.
Present: Representatives Banks, Coffman, Bergman, Roe,
Lamb, and Peters.
OPENING STATEMENT OF JIM BANKS, CHAIRMAN
Mr. Banks. Good afternoon. The Subcommittee will come to
order. Thank you all for being here today for the first hearing
of the Subcommittee on Technology Modernization.
I would first like to thank Chairman Roe for entrusting me
with this responsibility. I have spent much of the past 2
months studying VA's EHR modernization and the Military Health
System GENESIS Program and meeting the people working on both
of those efforts.
I never expected that electronic health records would be
such a major part of my service in the House of
Representatives. However, I do appreciate the central role they
play in the quality of health care delivery to every
servicemember, veteran, and practically every citizen in this
country.
I am also well aware of the stakes. EHR modernization is
inextricably linked to VA's ongoing reform efforts. If
successful, it will be one of the lynchpins of a more
responsive, agile, and efficient VA. If mismanaged, I fear a
daunting and disappointing setback.
That is why this Subcommittee is so important. Very rarely
has a body of the Congress been dedicated to oversight of one
program from its inception. Far too often, we only take an
interest in a government project when it has already become a
public scandal. This time it must be much different.
I commit to digging into the details and asking the
difficult questions. I commit to bringing the EHR modernization
into public view. VA is asking veterans to invest their trust
and all taxpayers to invest a huge amount of their dollars. The
public deserves to know what is happening.
I would also like to thank Ranking Member Lamb for being my
partner in this effort. We intend to set an example for how
well bipartisan oversight can work, even in 2018, when we
dispense with petty political games. Sometimes a big government
bureaucracy is like a freight train lumbering down the tracks.
The course may become dangerous, and the people driving the
train may even realize it; but the track was expensive to set,
and no one wants to alter it. Sometimes that train, that
bureaucracy needs some external help to course correct. That is
this Subcommittee's role.
VA's EHR modernization is still at the beginning of the
beginning, but a great deal has happened since June 26, this
Committee's last hearing on the subject. More is known now. We
know there will be disputes within the VA and other agencies.
We know leadership is crucial to resolve those disputes. We
also know that EHR modernization must be people centric. The
system must be designed from the bottom up and reflect what
veterans and health care providers actually need.
We have learned so many lessons from MHS GENESIS' early
mistakes. There is a great deal though that we still do not
know. We do not know if in any significant level of detail what
will happen and when in VA's EHR modernization. We do not know
precisely how the Cerner Millennium system will be structured
and configured.
The Department is still deep in its planning to flesh out
its schedule and fill in those blanks. VistA, other systems,
and VHA's processes are tightly interconnected. Once the
changes begin, we do not know what disruptions may result. We
also do not know what possibilities the future holds.
The EHR modernization promises native interoperability and
data, reams of clinical data to make veterans health care more
effective. It is important to take time and plan how to harness
that. We are here today to discuss specifically the role of the
Interagency Program Office. What is the IPO, and why does it
matter?
VA's EHR modernization and the Defense Health Agency's MHS
GENESIS Program must succeed together. That requires
cooperation. There will be debates, sometimes disagreements,
and decisions that must be made. There will be countless
actions every single day which must be coordinated between the
two programs.
Who makes sure all of that happens? Personalities will
change, but what is the constant? Maybe the two agencies work
together seamlessly at all times; maybe not. If not, Congress
expects the IPO to bridge the gaps. Congress created the IPO in
the 2008 NDAA to act as the single point of accountability for
DoD and VA to rapidly develop and implement EHR systems or
capabilities to achieve full interoperability--the single point
of accountability.
The IPO has been many things over the past 10 years, a
coordinating body for standards, the builder of an integrated
EHR system, which was quickly abandoned, a contributor to the
Joint Legacy Viewer, and the facilitator of interoperability
when the two Departments decided to modernize their EHR systems
separately.
But the IPO has never truly been the single point of
accountability. After trying practically everything else under
the sun over the past 10 years, VA and DoD have come to the
last remaining, hopefully best, solution to implement the same
commercial EHR. This is exactly what the IPO was intended for.
The question is, though, after so many twists and turns
over the years and the expansions and contractions of its
mission, whether the IPO is up to the task. And if not, how do
we make it up to the task?
With that, I yield to Ranking Member Lamb for his opening
statement.
OPENING STATEMENT OF CONOR LAMB, RANKING MEMBER
Mr. Lamb. Thank you, Mr. Chairman.
I also would like to thank Chairman Banks and Dr. Roe as
well for how well they have worked with me and my staff as we
get started here.
To use Mr. Banks' analogy, my focus is on the passengers on
that train. The veterans themselves have to remain our primary
focus. They need to get where they are going in a timely and
safe manner, and everything that we do here will be about
making sure that their care is at the highest standard of
health care worldwide, and that is what this project needs to
serve.
So, along the way, we should do whatever it takes to get
them to the destination, whether its change course or lighten
the load or add additional fuel or hire new engineers. Whatever
it is has to be on the table so that we can get the mission
accomplished.
This Committee, in my brief experience in Congress, has
lived up to its reputation as the last frontier of
bipartisanship in Congress, and that is largely thanks, I
think, to Dr. Roe's leadership. He has established a culture in
this Committee that I am very proud to be part of, and I think
that you will see that reflected in the work of this
Subcommittee as well. So thank you very much to you, gentlemen.
I think that this project has great promise, and in
addition to the care of our veterans, we need to focus on
accountability. That is something that I have seen can be
difficult to track in an agency as large and complex as VA, but
I know we can do it, and I know there is some great people
there trying to do the job.
I want to thank Mr. Windom for already meeting with my
staff to lay out some of the organizational chart. And just
like you would at the start of any military mission, I think
part of our goal here today is to establish exactly who is
accountable for what part of the mission and how quickly they
will be able to get that done.
So, with that, I am ready to begin. Thank you, Mr.
Chairman.
Mr. Banks. Thank you, Ranking Member Lamb.
I now would like to welcome our first and only panel who
are seated at the witness table. On the panel, we have the
Director of the Interagency Program Office, Dr. Lauren
Thompson, representing the Department of Defense. She is
accompanied by the Deputy Director of the Interagency Program
Office, Dr. Helga Rippen, representing the Department of
Veterans Affairs.
We also have Mr. John Windom, the Acting Chief Health
Information Officer and Program Executive Officer for the
Office of EHR Modernization in the Department of Veterans
Affairs.
Finally, we have Ms. Carol Harris, the Director of IT
Acquisition Management Issues at the Government Accountability
Office.
As will be the Subcommittee's practice, I ask the witnesses
to please stand and raise your right hand.
[Witnesses sworn.]
Mr. Banks. Thank you, and let the record reflect that all
witnesses have answered in the affirmative. You may be seated.
And, Dr. Thompson, you are recognized for 5 minutes.
STATEMENT OF LAUREN THOMPSON
Ms. Thompson. Chairman Roe, Chairman Banks, Ranking Member
Lamb, and distinguished Members of the Subcommittee, thank you
for the opportunity to testify before you today.
I'm honored to represent the Department of Defense as the
Director of the DoD/VA Interagency Program Office. And I'm
accompanied, as you mentioned, by Dr. Helga Rippen, the VA
executive in our office as the Deputy Director of the
Interagency Program Office.
The mission of the IPO is to lead and coordinate the
adoption of and contribution to national health data standards
to ensure interoperability across the DoD, the VA, and private-
sector health care providers. The DoD and VA represent two of
our Nation's largest health systems. Providing high-quality
health care to servicemembers, veterans, and their families is
one of the IPO's highest priorities, and health data
interoperability is essential to improving the care delivered.
The IPO is a collaborative entity comprised of staff from
both the DoD and the VA who have technical expertise in health
data standards and interoperability. The IPO serves as a
central resource for the DoD and VA monitoring industry best
practices and providing technical guidance to facilitate health
data exchange.
IPO team members work closely with the Office of the
National Coordinator for Health Information Technology and the
Department of Health and Human Services, as well as with
standards development organization, such as Health Level-7 and
others, to support the identification, implementation, and
evolution of national standards associated with both the DoD
and VA EHRs.
These activities are vital to providing the building blocks
for interoperability across the Departments. In April 2016, the
Departments with the IPO's support met the requirements of the
fiscal year 2014 National Defense Authorization Act, certifying
to Congress that their systems were interoperable with an
integrated display of data.
Currently, the Departments share more than 1.5 million data
elements daily. More than 415,000 DoD and VA clinicians are
able to view real-time data of more than 16 million patients
who have received care in the DoD and the VA through the Joint
Legacy Viewer.
The IPO plays an important role in monitoring DoD and VA
interoperability efforts as well. The IPO established a health
data interoperability metrics dashboard to identify Department-
specific targets for transactional metrics and trends, which
are routinely shared with Congress.
The IPO has also implemented the recommendations of the
Government Accountability Office regarding outcome-oriented
metrics to provide a basis for assessing and reporting on
interoperability progress. We work collaboratively with the
Departments on this.
The IPO also serves as a focal point for collaboration
across DoD and VA in their EHR modernization efforts. The IPO
has been actively supporting the Departments with the
development of a governance process to enable them to make
joint decisions regarding common aspects of EHR. The IPO will
facilitate the governance process, provide expertise and
guidance in implementing best practices, and capture artifacts
needed for decision-making.
DoD and VA are working to further enhance interoperability
through the implementation of the same electronic health record
system. The IPO will continue to work with the Departments as
well as the Office of the National Coordinator for Health
Information Technology and industry partners to ensure that
collectively we are advancing interoperability throughout the
health care industry.
Enabling health information exchange and interoperability
between EHR systems across DoD, VA, and private sector will
serve as the foundation for patient-centric health care,
seamless care transitions, and improved care for our
servicemembers, veterans, and their families. The IPO remains
committed to this mission.
Thank you for the opportunity to speak with you today. I am
happy to answer any questions you may have regarding the IPO
and ongoing work of the DoD and VA in regards to their
modernization efforts. Thank you.
[The prepared statement of Lauren Thompson appears in the
Appendix]
Mr. Banks. Thank you, Dr. Thompson.
Mr. Windom, you are now recognized for 5 minutes.
STATEMENT OF JOHN WINDOM
Mr. Windom. Good afternoon, Chairman Banks, Ranking Member
Lamb, and distinguished Members of the Subcommittee.
Dr. Roe, good afternoon.
Thank you for the opportunity to testify on the VA's effort
to modernize our electronic health record, commonly referred to
as an EHR.
First, I want to take the time to personally thank each of
the Members of the Subcommittee for your ongoing and really
unwavering support EHRM. Without your support, VA would not be
able to move forward on this critical initiative.
The Department is committed to providing the best care for
our Nation's veterans, especially access to complete medical
record. The new EHR system will improve access to quality care
and enable the seamless transfer of health data as
servicemembers transition from the Active Duty to veteran
status.
On June 5, 2017, VA announced its decision to replace
VistA, its legacy system, which is unsustainable and cannot
deliver critical capabilities to meet the evolving needs of the
health care market. Through this decision, VA is working to
adopt the same EHR solution as the Department of Defense
allowing patient data to reside in a single hosting site
utilizing a single common system.
The ultimate outcome of this initiative will enable the
sharing of health information, improve care, delivery, and
coordination, and provide clinicians with data and tools to
support patient safety. VA took several additional steps to
ensure this acquisition meets the needs of the veterans and the
clinicians who care for our veterans while also being a good
steward of the taxpayers' dollars by capitalizing on DoD
synergies.
VA conducted an interoperability assessment and worked with
leading health care organizations who recently implemented new
EHR systems. These steps were critical in identifying and
reducing potential gaps in VA's EHR contract.
On May 17, 2018, VA awarded a contract to Cerner to
leverage an existing commercial solution to achieve
interoperability within VA, between VA and DoD, and between VA
and community care providers. This contract contains the
necessary conditions fostering innovation and evolving
commercial technologies.
VA also ordered the first three task orders that include
project management, IOC site assessments, and data hosting. I
want to highlight these important aspects of the EHR
modernization effort, which will contribute to the overall
success of the program.
First, VA's implementation strategy will take several years
to deploy and will be an evolving process as technology
advances. VA's approach involves deploying the solution at IOC
sites to identify problems and correct them before deploying to
additional sites. The IOC sites will further hone governance,
configuration management, and solidify processes overall.
Secondly, VA has developed a change management strategy
that involves users in the field earlier in the processes to
determine their needs and quickly alleviate concerns.
Furthermore, EHRM has established clinical councils that
include nurses, doctors, and other end users from the field to
support configuration of workflows.
Finally, VA and DoD are working closely together to advance
transparency through governance from an interagency decision-
making perspective through the DoD/VA Interagency Program
Office. The Department's leadership, including myself, meets at
least monthly to verify working group strategies and course
correct if necessary.
By learning from DoD, VA will be able to proactively
address challenges and further reduce potential risk at VA's
IOC sites. As challenges arise throughout the deployment, VA
will work urgently to mitigate the impact of veterans' health
care.
We established a program office to provide oversight to the
new EHR implementation. The office is staffed with the
appropriate functional, technical, and subject-matter experts
to enforce adherence to cost schedule and performance
objectives, as well as quality objectives. This transformation
will support the Department's effort to modernize the VA's
health systems and ensure VA is a source of pride for our
veterans, beneficiaries, employees, and taxpayers.
Mr. Chairman, this concludes my opening statements. I am
happy to answer any questions that you or the Members of the
Subcommittee may have, and, again, thank you for this
opportunity.
Mr. Banks. Thank you, Mr. Windom.
Ms. Harris, you are now recognized for 5 minutes.
STATEMENT OF CAROL HARRIS
Ms. Harris. Chairman Banks, Ranking Member Lamb, and
Members of the Subcommittee, thank you for inviting us to
testify today on DoD and VA's Interagency Program Office and
its role in VA's Electronic Health Record Modernization
Program. As requested, I'll briefly summarize our prior work on
the establishment and evolution of the IPO over the last
decade.
As you know, VA and DoD operate two of the Nation's largest
health care systems, which provide coverage to millions of
veterans and Active Duty servicemembers and their
beneficiaries. Both Departments have long recognized the need
for shared health information systems and capabilities, the
benefits of which include making patient information more
readily available and reducing medical mistakes. To this end,
the IPO was established by law to act as a single point of
accountability for DoD and VA system interoperability efforts.
Unfortunately, this office has not come close to fulfilling
this objective. Between 2008 and 2010, we issued a series of
reports detailing how VA and DoD have not yet fully executed
their plan to set up the IPO. For example, key leadership
positions were either vacant or being filled on an interim
basis, and the office was not yet carrying out critical IT
management responsibilities in the areas of performance
measurement, project planning, and schedule.
Accordingly, we recommended, among other controls, the IPO
develop a project plan and detailed integrated master schedule.
And while the Departments agreed with the recommendation, their
subsequent actions were incomplete and the IPO remained
ineffectual.
In 2009, the IPO was rechartered and assigned
responsibility for establishing a virtual lifetime electronic
record for servicemembers and veterans. In February 2011, we
reported that the office had not developed an improved
integrated master schedule, master program plan, or performance
metrics for this initiative. We noted if these deficiencies
were not corrected, VA and DoD's ability to effectively deliver
capabilities to support their joint health IT needs would be
uncertain.
As such, we recommended that the Departments address these
management weaknesses. The Departments agreed with the
recommendation but did not take action, and thus, the IPO's
ability to effectively deliver this initiative continues to be
hampered.
In March 2011, the Secretaries of VA and DoD committed the
two Departments to developing a common integrated electronic
health record system. To oversee this new effort, in October
2011, the IPO was rechartered yet again to give it increased
authority and expanded responsibilities for leading the
integrated system effort.
However, in February 2013, VA and DoD abandoned their plans
for the system. We reported on this decision and found that the
Departments had not addressed management barriers for effective
collaboration on their joint health IT efforts. Among other
things, VA and DoD did not provide the IPO with controls over
essential resources, such as funding and staffing.
In addition, the Departments diffuse their responsibility
for achieving integrated health records, thus undermining the
office's intended role as a single point of accountability. We
recommended that the Departments ensure the IPO has authority
over dedicated resources, developing interagency processes, and
making decisions over the Departments' interoperability
efforts. Again, the Departments agreed with the recommendation,
but no action was taken.
In June 2017, the VA announced that it planned to acquire
the same commercial electronic health record system that DoD
has been acquiring. VA has since established a program
management office and drafted high-level plans for governance
of the electronic health record implementation.
Program officials have noted the governance bodies will not
be finalized until next month, and the officials have not yet
indicated what role, if any, the IPO is to have in the
governance process. As such, we are recommending that VA
clearly define the role and responsibilities of the IPO within
the governance plans for acquisition of the new system.
Because the IPO has historically been ineffective in
increasing interoperability and the VA has largely ignored our
previous recommendations, the Department has made limited
progress. In order for VA to successfully acquire the same
system as DoD, the Department must expeditiously and
effectively implement this recommendation.
That concludes my statement. I look forward to addressing
your questions.
[The prepared statement of Carol Harris appears in the
Appendix]
Mr. Banks. Thank you, Ms. Harris.
The written statements of Dr. Thompson and Ms. Harris will
be entered into the hearing record. Mr. Windom was unable to
submit written testimony for this hearing.
We will now proceed to questioning, and I yield to myself
to begin questioning.
To start with, Mr. Windom, I have to start by asking you
about the leadership turnover in the Office of EHR
Modernization. You might recall that this was my first question
for the Full Committee's June EHR hearing, so I hope this isn't
becoming a--somewhat of a pattern moving forward.
But in the immediate aftermath of Ms. Morris' resignation
on August 24, you were appointed the Acting Chief Health
Information Officer in her place. Our understanding at that
time was VA intended to conduct a search to fill the position
and that you would at some point return to your previous role
as program executive officer. Has that changed?
Mr. Windom. Sir, the--I've been with the effort since its
inception, including in uniform, as part of the drafting of the
determination and findings that drove this process. So I've
been with the VA for approximately 17 months in and out of
uniform.
The departure of Genevieve Morris really impacted no
continuity issues within our office. The Deputy Secretary, who
recently has come on board and I've been interacting with
daily, we're assessing the overall organizational structure.
From our perspective, we feel like we have no gaps in
leadership.
We have the full support of VHA and OI&T in augmenting the
present OEHRM, Office of Electronic Health Record
Modernization, and therefore, we feel like we, at this point in
time, have no gaps in leadership or in subject-matter
expertise.
I'm more than--was more than involved in the day-to-day
operations for the past 17 months even as Genevieve Morris
assumed the helm for approximately 1 month. So, sir, I guess I
would offer to you that we expect turnover--that's kind of the
way things go, not only in the Federal space but in the normal
commercial workspace--and that, you know, we wish Genevieve
Morris the best.
And in the same vein, you know, our chief medical officer
who departed, again, family wanted to be on the West Coast. We
have Dr. Laura Kroupa who immediately stepped in from the CMIO
role into the CMO role. She's been with us for 17 months, fully
understands her requirements. Again, we kind of pride ourselves
on no single points of failure, people being willing and ready
to step up. So, sir, that's where--that would be what I offer
as a response.
Mr. Banks. Appreciate that.
Mr. Windom, as well, the Office of EHR Modernization has a
chief medical officer position and a chief technology officer
position, in other words, a physician executive and a general
IT executive. Health informatics is somewhat different. It
blends the two competencies. Do you believe it is valuable to
have a health informaticist as the leader or one of the leaders
at your office?
Mr. Windom. Yes, sir, absolutely. I think your--the term--
the use of the word ``leader'' is the critical piece. I pride
myself on knowing what I don't know and knowing what I do know.
And we've got an incredible subject-matter base throughout the
VA portfolio for me to access, including support contracts in
Booz Allen Hamilton and other access to other consultants where
we can draw on the expertise on a moment's notice.
Mr. Banks. So, with that, is there anyone working in the
Office of EHR Modernization who has managed an EHR
implementation in a large health system to its completion?
Mr. Windom. Sir, the--we have subject-matter experts that
are being provided to us by Booz Allen Hamilton as part of our
support contract that are delivering who have done just what
you've just--you've captured, which is work in EHR
implementation from start to finish. And so I'm comfortable
with the support we have from the commercial--
Mr. Banks. So it's a yes?
Mr. Windom [continued].--environment. So that is a yes.
Mr. Banks. Okay.
Mr. Windom. Do we have the expertise on the government
side? I would offer limited.
Mr. Banks. Okay. All right. Mr. Windom, your position in
MHS GENESIS in the Defense Health Management System's
Modernization Office was as the program manager. Is that
correct?
Mr. Windom. Yes, sir, that's correct.
Mr. Banks. Okay. And when did you hold that position?
Mr. Windom. I held it from October 2013 through--I departed
in November/December of two thousand and--my years are running
together. I'm getting older--2015, so approximately 3 years,
sir.
Mr. Banks. So what--what were--can you tell us then what
were some of the other leadership positions at MHS GENESIS in
addition to that one?
Mr. Windom. My primary position was the program manager, so
I report--
Mr. Banks. What were some other positions that existed?
Mr. Windom. I'm sorry, sir. Would you please repeat that?
Mr. Banks. Within the organization.
Mr. Windom. Well, we've had chief engineer. We had system
engineers. We've had testing leads, obviously a functional
lead, chief medical officer. We had a, you know, a technical
lead and a CIO/engineer, system engineer. We had no role called
a CHIO, chief health informatics officer. That seems to be an
evolving role in the commercial--
Mr. Banks. All right. I don't mean to cut you off. Before I
yield to the Ranking Member, do you believe the chief health
information officer position is necessary and beneficial, yes
or no?
Mr. Windom. I have been unable to find in any
implementations in the commercial the naming of a chief health
information officer. I find that that skill set is offered from
our CMIO community and from our informatics community in
general.
So, to answer to your question, I believe that the
leadership role is the fundamental and most important element
of this bringing together the requisite expertise to deliver to
the mission.
Mr. Banks. Thank you. My time has expired.
I yield to Ranking Member Lamb for his questions.
Mr. Lamb. Thank you, Mr. Chairman.
Mr. Windom, who do you believe is the person within VA who
is primarily accountable for the success of this project?
Mr. Windom. Sir, my ego would say me, but reality is the
DefSec, Mr. Jim Byrne. I report to him as mandated by, you
know, the various elements of--from congressional mandates
regarding who should oversee the funding of this project. So my
ego, my accountability, in reality, his accountability, and I
think that relationship is--supports that.
Mr. Lamb. Thank you.
Now, could you just tell me succinctly, what do you view as
the role of the IPO when it comes to the actual successful
implementation of this project?
Mr. Windom. The IPOs, sir, is--I think is a--the
facilitator between DoD and VA. When I say that, I mean clearly
DoD has a mission set of requirements. VA has a mission set of
requirements. It's impossible as we execute our day-to-day
operations to be absolutely aware of what's going on in the DoD
portfolio, and I believe vice versa.
I think the importance of the IPO is that they do have the
visibility under both portfolios and therefore can facilitate
or bridge the gaps of understanding between the organizations
and to ensure that we are aware and in tune as to what, if you
will, are problems that are being countered, lessons learned
being shared, things along that line. So I would offer a
facilitator between the two organizations and support of
overall success, mission success for both organizations.
Mr. Lamb. And so it sounds like you view it as--and this is
just a yes-or-no question so I can move on. Do you view it
mainly as their responsibility to provide information to you?
Mr. Windom. I believe it's not only information but also
consult, guidance as appropriate, and also recommendations and,
if you will, endorsement of good ideas, So the full spectrum,
sir.
Mr. Lamb. Okay. Do you believe that the IPO has decision-
making authority over you with respect to any aspect to this
project?
Mr. Windom. I do not believe that.
Mr. Lamb. Okay. Thank you.
Dr. Thompson, same question for you. Can you just define
for me very succinctly what you view the role of the IPO to be
in this project?
Ms. Thompson. Thank you for the question, sir.
The IPO serves in a convening role, a coordinating role. We
facilitate the information sharing from the experiences of the
DoD's MHS GENESIS deployment at initial sites to the VA and
conversely information from the VA as their program is being
developed to share with the DoD.
We do, as I had indicated in my opening statement, we have
been working in collaboration with both Departments, been
developing a process for governing, how decisions will get made
as they arise, where there are--when decisions need to be made
regarding the common electronic health record that is able--
that has evolved since the VA made their announcements to
purchase the same system as the DoD.
Mr. Lamb. But do you think that you have the decision-
making authority to establish how that governance structure
looks, or would you agree with Mr. Windom that you're basically
making recommendations to both entities?
Ms. Thompson. At this point in time, we make
recommendations. We do not have the decision-making authority.
Mr. Lamb. Okay. Thank you.
Now, Ms. Harris, having heard both of those answers, can
you fill us in in the time remaining, do you think that there's
a further definition of IPO that needs to happen, or are there
shortcomings in what we've heard here today?
Ms. Harris. Well, according to the law, the IPO is supposed
to be the single point of accountability, so that would include
responsibility, authority, and decision-making
responsibilities. So I think that how they've responded is in
conflict with the expectations set out by law.
Mr. Lamb. And would you agree that, as of right now, it
appears that we lack a single accountable individual person or
group who will be accountable for the joint success of this
project, meaning the actual interoperability that we're trying
to achieve between the two agencies?
Ms. Harris. That is correct, yes.
Mr. Lamb. Okay. Thank you, Mr. Chairman. I yield back.
Mr. Banks. Thank you. I now yield to the Full Committee
Chairman of the House Veterans Affairs Committee, Dr. Phil Roe,
for 5 minutes.
Mr. Roe. Thank you, Mr. Chairman.
I'm going to give a little history lesson here, and then
we'll go with questions. I remember sitting here, and I think
maybe Mr. Coffman was here, when we spent $1 billion of
taxpayers' money to try to get VistA and AHLTA to speak to each
other, and it was a failure. And I think that's--was
astonishing to me that we could get rid of $1 billion and
accomplish not anything.
That was several years ago when you all went through Mr.--
when it went through the chronology as Ms. Thompson did. I
don't want to do that again. I think Secretary Panetta and
Shinseki sat right at that dais and said: We failed.
We then--I think the decision was made by the DoD and then
our previous VA Secretary to move on and try to have the same
system. I thought that was a good decision that was made.
One of the things that I want to get into, and I think it's
very important what both the Ranking Member and the Chairman
have said, is about who's in charge--you know, who's in charge
of this thing. And I'm going to quote the Yogi Berra: If you
don't know where you're going, you might end up someplace else.
And that's my fear that if we don't have somebody in
charge, that that's going to happen. And so we need to
establish that this--today when we leave here who can the
Chairman and the Ranking Member contact when they need to know
something about this program.
And I took the--I've implemented the electronic health
record system, and it is difficult. And every VA hospital I go
to, I try to explain to them that this--and talk to the people
and to veterans that this is going to be hard and you've got to
be patient with the providers and the hospital when this
implementation takes place.
And I know from our visit out at Fairchild and Madigan--I
know the Chairman has been out there--it was less than smooth,
to be kind. And, Mr. Windom, you mentioned any time you put
EHRs in, it slows you down. There's no question about it. I
found myself sitting at 8 o'clock at night, 9 o'clock at night,
entering data in the computer from my day's work, a really fun
thing to be doing.
And I know you mentioned here that you would look at a hit
of 10 percent. I think you're going to have to look, if you
look at Madigan, a much bigger hit in productivity, and that
has slowed them down initially 50 percent. And they had to hire
a number of people to get up to speed.
And one of my concerns is, is all this at this 30,000-foot
level is fine, but there's a nurse and a doctor and a health
care people out there that are seeing a patient. And if they
hit a blind canyon, what do they do? Because there's six other
people waiting to see them right then.
And apparently what happened when DoD was putting this out,
they had to call a number here in D.C., and, you know, it was
1-800, hold, and ``We'll get back to you, and there are 1,000
people in front of you,'' and yet there's a provider out there
that they were fearful that they would put inaccurate data in
and so forth and actually harm patients.
Can we be assured that the training--and what I found out
was--I didn't care about all that. What I cared about: Can I
negotiate this electronic system and get this data in there
accurately, because after I'm long gone somebody is going to be
looking at this data making clinical decisions based on the
patient's well-being?
Can we be assured that there will be adequate--Cerner has
been in our office. Can we be assured that there will be help
there for those providers, and have we talked to those
providers instead of putting a top-down approach? Have we found
out what they want and what works at their hospital after this
initial rollout? And, Dr. Thompson, you or Mr. Windom, either
can take those questions.
Mr. Windom. Thank you, Dr. Roe.
The 10 percent number, I'm not sure. We have articulated, I
think, at various aspects anywhere from 10 to 50 percent
understanding that there are inefficiencies introduced by
business transformations, and our job is to be preemptive and
proactive.
And I think we are, with the support of VHA, in making sure
that we have strategies that augment the workforces that are
there as part of our implementation strategies. I think that's
a key element, and we will continue to monitor those. I can--
yes, sir.
Mr. Roe. No. I'll tell you what really--when I was at
Fairchild, what really got me was they had taken a year to put
10,000 healthy people--and VA have healthy people. Most of them
are not. And what--the data that was entered--was entered into
the record was very basic data, and you had to use the Joint
Legacy Viewer to get into the weeds.
And we need--in other words, we were going to have to run
that system parallel until, I guess, for 70 years or 90 years
until every veteran who went in there was gone. And then I
thought: Well, that's a disaster. If we've got to run two
systems to be able to have an EHR, that defeats the purpose of
it.
So can we be assured that all of that data will be moved
onto one system so that, at one point in time, we can cut the
lights off on the old and be totally beholden to the new one
with that data backed up and shared somewhere?
Mr. Windom. Yes, sir. It is our intent to migrate all data
into the healthy intent platform that Cerner manages. We will
have complete access to data and still own the data. So that's
absolutely our strategy. I think you hit the nail on the head
in a myriad of ways, and I think you hit the nail on the head
when you said this is hard.
And so we are going to continue to leverage our partnership
with DoD. We're going to continue to learn from that, and we're
going to continue to do the absolute best we can not to impact
that important care being delivered to our veterans.
So I can't disagree with any of your remarks, sir, other
than we're learning by the day, and we're going to continue to
develop our implementation and integration strategies to
minimize that impact on our veterans and on the clinicians that
serve our veterans. So--
Mr. Roe. I yield back, and hopefully, we'll have a second
round.
Mr. Banks. Thank you, Chairman Roe.
I now yield 5 minutes to Mr. Peters.
Mr. Peters. Thank you, Mr. Chairman. I am glad that we're
having our first Technology Modernization Subcommittee hearing
today. And sorry I'm covering two hearings, so I didn't--I
wasn't able to catch all the testimony. But I'm looking forward
to working with my colleagues here to make sure that veterans
remain the priority throughout the project.
I served my first two terms on the Armed Services
Committee. This is my third term, and I'm honored to serve on
the Veterans Committee. One of the things I always wondered and
laypeople always wondered was why you'd have two electronic
health records for that set of people. Every single veteran
comes from the Department of Defense. So we scratched our head
about this, and we all understood there was kind of standoff
between the DoD and the VA in terms of how they wanted to
approach it.
So I recognize that the IPO, the Interagency Program
Office, provides an important role in sharing information. But
I think Mr. Lamb's questioning showed pretty clearly that
there's really no one there to break the ties or resolve the
differences. It seems to me that the same kinds of differences,
whether they're cultural or historical, exist today as they did
when I came in.
I guess my question for Ms. Thompson or Dr. Thompson is:
You had mentioned that the IPO, the DoD, and the VA planned to
set up governance bodies to oversee the effort. How would--what
would those look like, and how would the bodies differ from the
current process? And then I'm going to ask Ms. Harris to
address the same issue, what you think it should look like. Dr.
Thompson.
Ms. Thompson. Thank you for the question.
So, first, let me point out that there are existing joint
governance bodies in place today, and we intend to use those
bodies to the extent that we can. What we are proposing as new
bodies are specific to making decisions about the configuration
of the electronic health record that will be implemented at the
sites in both Departments.
What we are proposing are three bodies, a joint functional
governance board and a joint technical governance board and a
joint decision-making board. The premise of the governance is
that the decisions are made at the lowest level possible. We
have clinicians working together side by side today, technical
experts working side by side today to help determine the path
forward and solve problems.
When they cannot agree, then only at that point would a
decision be escalated to respectively either a functional
governance board or technical governance board. And we fully
believe that those bodies will be able to come to agreement,
and only if they can't would those decisions then be escalated
to a decision board which would be comprised of those in the
Departments with the authority to make decisions regarding the
configuration of the electronic health record.
Mr. Peters. Ms. Harris.
Ms. Harris. Sir, I think, based on the IPO's past history,
I think it's evident that they never had the clout to either
mediate and resolve the issues between VA and DoD as it relates
to interoperability. So I think when it comes to the law itself
of having a single point of accountability, the IPO was never
set up to succeed there because neither of the Departments were
willing to relinquish control.
Mr. Peters. Right.
Ms. Harris. I think in terms of what you would see in
leading organizations,--what they have shown based on our past
work is that you have a single executive level entity that is
the point of accountability, and it's just one body as opposed
to multiple bodies, and it has to be at that executive level.
So that's something that we would expect to see, you know,
moving forward when VA and DoD establish their joint
governance. Certainly I would expect to see it at a minimum at
the Deputy Secretary level, you know, VA's Deputy Secretary and
his counterpart at the DoD leading this joint executive entity.
Mr. Peters. Do you anticipate that the joint effort would
actually have new decision-making authority that would bind
both agencies?
Ms. Harris. That would--I mean, in order to be the single
point of accountability, they would have to have decision-
making authority in order to be able to arbitrate issues and
make decisions so that if compromises are necessary--
Mr. Peters. Yeah.
Ms. Harris [continued].--that they have the authority to
make those decisions. That's essential.
Mr. Peters. And is that something that we've seen in other
agencies? Is there a model for this that we can borrow?
Ms. Harris. Unfortunately, we've never seen it work well
when we've seen those joint collaborative efforts. I mean,
there's a reason IT is difficult. And certainly, you know, when
you're talking about the two largest health care networks in
the Nation, I mean, it compounds that complexity. However, we--
Mr. Peters. Well, I would just--I'm out of time, but I
would just offer that either the President has to do this or
the Congress has to do this, because I don't think this thing
gets created without some action by us. And the only people--
the only person that both agencies report to now is the
President of the United States. And if--I think also Congress
would have a role to create such an agency as well. So I
think--I look forward to the current--the coming work. Thank
you. I yield back.
Mr. Banks. Thank you.
I now yield 5 minutes to Mr. Coffman.
Mr. Coffman. Thank you, Mr. Chairman.
Ms. Harris, from a Government Accountability Office
standpoint, if you were to look at how we wasted $1 billion and
got nowhere on this interoperability of health records, isn't
it that you had two large Federal entities with neither--both
considered to be coequals with neither one in charge and people
in the middle, you know, trying to negotiate with them
unsuccessfully, is that--does that characterize where we are--
where we were?
Ms. Harris. Yes. I think that in the past situations what
we've seen historically is that when everyone is responsible,
no one's responsible. And so I think that's what has led us to
where we are today since, you know, we've had these subsequent
interoperability initiatives, including the integrated
electronic health records initiative between DoD and VA, and
unfortunately, because of the lack of collaboration on the part
of both Departments, that's why we're here today.
Mr. Coffman. So now what we have going is creative,
strengthen this IPO to hopefully move forward. I think you
still have two big coequals out there. I'm not sure that the
results are going to be different. Isn't it better--wouldn't it
be better for--to make a decision, whether by the Congress of
the United States or preferably the executive branch that would
put one of these two players in charge to say either it is the
DoD or VA, and the other player certainly is going to have
input, but it's going to have to follow whatever--if DoD is the
lead agency, then DoD is going write this thing, and VA is
going to have to follow or vice versa.
But to have--I think to have the IPO with the expectation
that these two big players--that life is going to be different,
I'm not sure life is going to be different. And I worry that
we're going to waste another $1 billion on this.
And so I would--I think to my colleagues, and would love to
get your input on this, wouldn't it be better--I mean, if we
look back, clearly--this would be--if either DoD or VA were in
charge of this, and we're not coequals, I think this would be
done by now. I don't think we waste $1 billion. I'd love your
input on that.
Ms. Harris. Well, I think that--I think, number one, if the
IPO continues the way that it is operating today, we are going
to continue to have dysfunction in moving forward, and
unfortunately, you know, we want to prevent that.
We have not done work on MHS GENESIS, so I can't speak to
the DoD side, and so I wouldn't be able to weigh in on whether
DoD or VA should be taking the lead. I think that's something
that the Departments should discuss as they define the roles of
joint governance moving forward for their two implementation
efforts.
Again, I--perhaps Mr. Windom might have some perspectives
as well, but I think that's something that the Departments have
to negotiate amongst themselves.
Mr. Coffman. Mr. Windom.
Mr. Windom. Sir, I would offer that our governance is
evolving. It's impossible to create a governance structure that
can--handles all matters that may arise. As a matter of fact,
we think we have a notional governance structure that is being
tested through use cases as to how it would function and render
decisions that you speak to. I think we are working through
that process right now.
Again, the mission set went from a JOV-dominated element
for interoperability to now two EHRs that are going to make us
interoperable. That's a new mission set. That's a new oversight
responsibility, and I think we're working through those
challenges, sir. And I think we will have a governance
structure that works. And as you know, any business
transformation typically involves challenges with governance.
So we will continue to work that, sir. We understand.
Mr. Coffman. So where I might disagree is you said we will
have a--it will evolve, and we will have a governance structure
that will work. And I think given the restraints that you're
under, I think that that's pretty optimistic, and I think it's
good. That's leadership on your part.
However, that still doesn't define the fact that we don't
have a lead agency in charge. I still think there is a role for
an--the IPO with the lead agency in charge. But I--you know, I
think we owe it to the taxpayers, we owe it to our Active Duty
and our veterans to get this right, and I believe that we've
got to define that somebody who's going to be the lead agency--
one of these two that's going to be the lead agency here.
Mr. Chairman, I yield back.
Mr. Banks. Thank you.
I now yield 5 minutes to General Bergman.
Mr. Bergman. Thank you, Mr. Chairman.
Thanks to everybody for being here.
Now, as I look at the timeline here on the documents
presented, it kind of goes, you know, back to the future. In
January 2008, when we, Congress, created the Interagency
Program Office, I was still in command of the Marine Corps
Reserve. And in April of 2009, when work on the virtual
lifetime electronic record began, I was still in command. Okay.
So I didn't really think about it in that depth until we
were sitting here today, and you look at how fast time flies.
I'm not sure which goes faster, the time or the $1 billion out
the door. Okay. The point is we cannot recover time ever. We as
a Committee, we as a Congress could, you know, put more money
into a program. We can always do that, but is that the right
answer for this Committee, who you've heard said several
different ways, works bipartisan. Are we throwing good money
after the bad?
And I guess what I was, you know, hoping for is to hear
some level of testimony that instills confidence in us that
we're not writing one check after another and dropping it into
a black hole because, in the end, what we're talking about is
creating a health record when a young man or woman comes into
the military and having it be their final health record, if you
will, when they are at the end of their time on this Earth. I
don't see it.
So, having said that, let's talk a little about--I'd like
to hear from you as to some of the whys we're not. In fact, I
took a note that, Mr. Windom, you said joint governance is
evolving. Evolving, okay, there's a lot of things that evolve.
Do you or any--would any of you at the table be willing to
venture a statement, making a statement as to, are you
satisfied with the rate of evolution? Anybody could answer.
Mr. Windom. Sir, I'm very satisfied with the rate of
evolution. And this is why I say it's evolving, is that the as-
is state of the enterprise within VA is different than the as-
is state of the enterprise within DoD. We've acquired the same
commercial electronic health record, and now we're
understanding the gaps between how we sought to implement and
how DoD is implementing.
And so those gaps have to be reconciled, and they have to
be reconciled through governance. We've got site surveys that
are ongoing that are discovering new things within the
framework of the VA environment that have to be also taken into
consideration.
Our job is to deliver more capabilities than is presently
being delivered within the VA as is DoD's. We didn't buy a new
system to implement the same thing. And so there is some cross-
pollinization. There is some hard work that has to be done.
There's some hard--
Mr. Bergman. Let me ask you a question--
Mr. Windom. Yes, sir.
Mr. Bergman [continued]. --because I don't want you to run
out my time.
Mr. Windom. No. No problem, sir.
Mr. Bergman. Okay. And the point of this is we talk about
vying--you know, you've got two big dogs vying for control, in
some ways, of a project. What can Congress do--what can
Congress do to set the stage for--I don't care if it's you
agree in the joint governance that DoD is going to have it for
the first year, and then you're going to do a handoff with a
baton and hand it to the VA for the second year, don't care,
because as we evolve, the situation is still there; people in
positions change. Is there something that Congress or through
the Veterans' Affairs Committee can actually do through
legislative process to actually jump start this evolution?
Mr. Windom. Sir, I think you did jump start it when you
provided $782 million in the year of execution, fiscal year
2018. And so we are very respectful of your investment in us.
And so I think you have to let us--
Mr. Bergman. Are you guys going to be able to then as
hopefully will--you know, most of us will be back here to look
you in the eye a year from now and get accountability up, you
know, update as far as the--where we are?
Mr. Windom. Sir, that's the only way I know how to do it. I
spent 30 years in the military. Cost, schedule, performance
objectives have been at the forefront of any program that I've
worked in or led, and so I expect to be held to the same
standard. So we look forward to giving you and presenting you
with the data that supports our adherence and exceeding of
cost, schedule, and performance objectives or rationale why we
didn't. So we look forward to that scrutiny, sir.
Mr. Bergman. The point is I look forward to being here and
whether it be in the Technology Committee or whether it be in
the Oversight Investigation Committee--
Mr. Windom. Yes, sir.
Mr. Bergman [continued].--because we've got things moving
to a small extent. And I see I'm over my time, and I yield
back. But we need to keep the sense of urgency at all levels
moving forward.
Mr. Windom. Yes, sir.
Mr. Bergman. Thank you, Mr. Chairman.
Mr. Windom. Thank you, sir.
Mr. Banks. Thank you. We will now proceed to a second round
of questioning, and I will begin.
Mr. Windom, this is a diagram--is it on the screen? Yes.
Okay. This is a diagram from your office depicting VA's
Committees, boards, and councils, and DoD's equivalents that
oversee the EHR modernization. Can you please take a moment to
explain what these are, what they do, and how they interact
with each other?
Mr. Windom. Sir, I can't really see the screen, but I think
I have the boxes memorized. So at the lower level we've got
technical and functional governance boards. Again, Dr. Thompson
mentioned for us governance to be successful, things have to be
resolved at the lowest level. Okay.
If everything has to be elevated to an executive council or
a government integration board, then we're really not
succeeding. So really it's the clinicians talking to the
clinicians, the technicians talking to the technicians. And you
see, other than the names being changed, we pretty much mirror
on the VA side what DoD is doing in the name of TSWGs and other
things.
So really those four layers of governance that allow pass
of resolution--thank you. Now I've got to put on my glasses. So
the Steering Committee at the top is chaired by the DefSec. The
Governance Integration Board, No. 2, is chaired by me, and it's
bringing together the CMO and the CTO for elements that they
were under--unable to adjudicate at the lower level. And then 3
and 4 reflect the functional and the technical governance board
that I indicated chaired by the CMO and the CTO respectively.
And then you have that lowest level of governance where we hope
at the functional level and the technical level, which is No.
5, things are really being resolved. The more we have to
elevate, the less we are succeeding.
Mr. Windom. There's absolutely no way. We will have
thousands of governance elements, and I hope to having risen to
block No. 1 only a handful for the executive levels like the
DepSec and VHA and the CIO. Because, again, that is going to be
a slower, arduous process where things can get resolved in
block No. 5 at a more efficient--and those are the people that
are being called upon to execute using the new HR, and so, sir,
that's--an explanation of the left side.
Mr. Banks. I need to move on.
Dr. Thompson, the middle of the diagram there's a box,
marked, quote, ``facilitated by IPO.'' Can you please explain
what these boards are that the IPO facilitates, and how does
your office do that?
Ms. Thompson. These are the three boards that I mentioned
that are not in place yet but that we are proposing be put into
place. A joint technical board, a joint functional board, and a
joint decision board. The proposal is that the IPO serve as the
executive secretariat for these boards as we serve in that
capacity for other joint bodies. In that role, we would take
responsibility for planning the meetings and developing the
process and capturing decisions that are made at the meeting,
ensuring that the artifacts are captured and that the decisions
made at the meetings are communicated appropriately.
So, in effect, we would be managing the proceedings of
these meetings, bringing together the appropriate people, the
decisionmakers.
Mr. Banks. Could you elaborate on when they would be
established?
Ms. Thompson. We are in the final stages of formalizing a
proposal to our Joint Executive Committee, which is co-chaired
by the Deputy Secretary of the VA and the Undersecretary for
Personnel and Readiness. It is our hope to be able to bring
that before them for consideration in the near future.
Mr. Banks. What is the near future?
Ms. Thompson. Within the next few months.
Mr. Banks. Okay.
Ms. Harris, the middle portion of this diagram, where the
IPO coordinates between the DoD and VA, has existed for some
time. Isn't that correct?
Ms. Harris. Yes, that's correct.
Mr. Banks. Okay. How well, Ms. Harris, has this structure
performed in the past and how well has the IPO been able to
drive interoperability projects between the two Departments?
Ms. Harris. The IPO, based on history, has demonstrated
they have not had the clout to be able to, again, mediate and
resolve the issues between the two Departments. So the
performance of the IPO has been relatively lackluster, but
there is an important role for the IPO. I mean, they play a
critical role in identifying interoperability standards, and
they certainly have a role to play in measuring the progress
and performance of interoperability between the two
Departments. So certainly there is a role for the IPO to play.
However, you know, based on what we see here, I mean, they
are not acting as the single point of accountability, again as
called for by statute. So I think, you know, one of the things,
going back to one of the earlier questions of what Congress
could potentially do, one thought for consideration would be to
relieve the IPO of the legislative requirement to act as a
single point of accountability. I think that, again, when you
look at leading organizations, that single point of
accountability should be at the executive level.
And one of the things that strikes me, when you look at
this org chart, I mean, you count the number of boxes. There
are at least 16 boxes here, which shows that accountability has
been so diffused so that when wheels fall off the bus, you
can't point to a single entity who is responsible, and that is
a problem. And so, again, focusing on a single point of
accountability is critical in moving forward to make sure that
interoperability is functional.
Mr. Banks. Thank you.
My time is expired. I now yield 5 minutes to Ranking Member
Lamb.
Mr. Lamb. Thank you, Mr. Chairman.
So, Dr. Thompson, the proposal that you've laid out of the
three bodies, you used the term ``executive secretariat.'' Do
you agree with Ms. Harris that that is--that is inconsistent
with the statutory mission of IPO being a single point of
accountability? Do you agree that those two things are not
consistent with each other?
Ms. Thompson. In practice today, we do not function as a
single point of accountability. Our approach is to--is
collaborative in nature, to convene the decisionmakers of the
Departments and facilitate a decision in that way. And I do
believe we've been very effective in doing that.
Mr. Lamb. Okay, so you do agree, then, that the way you're
functioning today and the way you would function under this
proposal would not be consistent with the statutory objective
of being a single point of accountability?
Ms. Thompson. Not in regards to electronic health record
modernization. We have served in that capacity in regards to
moving forward interoperability in health data exchange.
Mr. Lamb. Would your office be capable of fulfilling the
statutory mission if given something that it doesn't have right
now?
Ms. Thompson. We would be more than willing to fulfill that
role. We are not currently staffed or resourced to fulfill that
function as I would envision it would need to be if we were to
serve in that capacity.
Mr. Lamb. And what is it that you would need in order to
serve in that capacity?
Ms. Thompson. We would likely need additional people to
support the function.
Mr. Lamb. Okay. Any idea how many people?
Ms. Thompson. I would not want to take a guess at that. I'd
be happy to take that for the record and get back to you.
Mr. Lamb. Okay, I would appreciate that.
Do you agree that, under the proposal you've discussed
here, with the three bodies, it doesn't appear that in that
proposal there is anyone who is an arbiter between DoD and VA.
Is that right?
Ms. Thompson. There is not a single individual. Our
approach is for all of these bodies to be co-chaired by a DoD
and a VA decisionmaker.
Mr. Lamb. Right. But there would essentially be an even
number of--of votes.
Ms. Thompson. There's not--
Mr. Lamb. And if it was 1 to 1--
Ms. Thompson. There's not an individual who is a
tiebreaker.
Mr. Lamb. Right, okay.
Mr. Windom, are you aware of this proposal, of the three
bodies?
Mr. Windom. Yes, sir, I am.
Mr. Lamb. Okay. Any thoughts on how that could work?
Mr. Windom. Sir, I believe that the use cases that we've
been running through this process have been yielding successes.
So, again, my commitment is: Extremely dynamic environment. We
will continue to assess our governance structure to make it as
efficient as we possibly can. And so, at this point in time, I
would offer, I think, that is a very viable governance
structure, sir.
Mr. Lamb. So, correct me if I'm wrong, I just want to sum
it up. Do I have it right that your view is basically that this
is kind of being worked out on the fly, day to day, through the
testing and examinations that you guys are doing, and you're
raising issues to DoD as they come up? Is that a fair way of
saying it?
Mr. Windom. I would say, we started governance--this
governance discussion well over--almost a year ago. And so as
discoveries are made, this is being refined. Again, we're in--
Mr. Lamb. What is being refined, though? Because this
proposal of the three bodies does not exist yet, as far as I
can tell, so--
Mr. Windom. No. It--which is one of the refinements that
have been made is the need for these three bodies as we
adjudicate issues between DoD and VA.
Mr. Lamb. Right.
Mr. Windom. Again--
Mr. Lamb. But right now that is not happening in any formal
way. That's kind of what I'm asking you. Seems like it's
happening on--
Mr. Windom. Not in a formal way, you're correct, sir. It
is. And I guess I want to make a comment about the GAO's
comments and Ms. Harris' comment, is that there's 16 boxes on
there because there are a myriad of mission sets, that there's
no single body that is qualified from technical to clinical
perspective. Our job is to manage those and have elevation
opportunities through the give and through the executive
council to resolve things that are unable to be resolved at the
lowest level. What I can't impress upon the Committee enough is
that governance has to be successful at the lowest possible
level. Things can't rise to the superior level on every matter.
Mr. Lamb. Thank you.
Mr. Chairman, I yield back.
Mr. Banks. Thank you.
I yield 5 minutes to Dr. Roe.
Mr. Roe. Thank you, Mr. Chairman.
And a couple things, everyone--every Member on this dais
has been in the military, and we all understand the command
structure. I understand--and when I had my little two silver
bars and then finally got a little--I would have to absolute
him every time because he had three stars. I got that. There's
nobody that we have as a three-star here.
And what I think Mr. Coffman is concerned with in his
question, his concern is we're going to have another Denver
fiasco if we don't have somebody that the buck stops here. And
we had a $600 million project end up being a $2 billion
project. This would be a $40 billion if we triple the cost of
this thing. So that's why it is absolutely critical--and Ms.
Harris has said over and over again--the private sector where I
came from, whoever signed the check was in charge. They were
the ones that were responsible, either to the shareholders or
to the partners in the group to make those decisions.
And what I see coming here is we've got to get that worked
out, whether it's someone from the executive branch or--and I
would argue that the VA has different needs than the DoD does.
Those are different systems. They serve different patients. And
the VA system is gargantuan compared to what the DoD is doing.
So I think that should be taken into consideration when you're
working out this command or this guidance structure. So that's
just my two cents' worth on that.
If we haven't learned anything today, I think we've learned
that, that we're going to end up in a Denver if we don't
decide--or somebody--where the buck stops.
And, Mr. Windom, I totally agree: Everything doesn't need
to go to the boss. There needs to be somebody, like I said, at
the provider side, to help them navigate this. They don't need
to call you for that, to find out how to get this button
punched to get there. So I got that. One of the things that I
would like to know and I think it's critically important,
clinically, that you said that you--Mr. Windom, you said it was
your intent to get to a single system, but there was no
commitment to that. Are we committed to get off the legacy
system and into this one single system?
Mr. Windom. Sir, absolutely, committed.
Mr. Roe. Okay.
Mr. Windom. The pivot strategy is an important piece of
this. Again, I think everyone knows that we have to run these
systems in parallel for a period of time. My job is to drive
down the amount of time we have to run these systems
simultaneously. That's taxpayers' money being expended.
We want to move--IOC is critical. We're going to be
assessing during IOC what things can be deployed sooner, what
things can be deployed out of sequence, to facilitate turning
things off, sir, as you're alluding to. Absolutely, we want to
pivot from the existing legacy systems to the new her, but we
want to do it without disrupting care or introducing
efficiency--inefficiencies in the care of veterans. So we have
to be judicious.
Sir, I've heard you say a number of times, the schedule
won't drive us. We have to do what's right. We have to be
committed to our veterans every step of the way. And that's
what we're going to deliver to you, is a pivot strategy and
then execute to that strategy, that, in fact, takes care of our
veterans.
Mr. Roe. Where I see the--this is just my view after
listening to this today. Where I see the IPO as, is that when
you go to Bremerton and Madigan and you find out that the
pharmacy has been slowed up, and that that they can pass that--
this is what happened when we rolled this out. This is what you
shouldn't do, or this is what you should do to ramp up to avoid
the slowdowns that occur. That--I don't think they need to be
involved in every decision going on.
But somebody, just like when Dr. Shulkin said we're going
to use the Cerner System, one person made that decision. It was
a gigantic decision, but when he took advice from a lot of
people--but one person had to sit down and sign his or her name
to that document so they could get it done. And there needs to
be a buck-stops-here person in this organization, I think, so
that those things we learned in Spokane and Seattle, the IPO
can pass all that information along very well.
But I don't think they need to be--they need to be a flow
of information and best practices, not the person that says:
Here, no, we're not going to do that.
And there needs to be that person out there, so that
backstop out there somewhere.
I yield back.
Mr. Banks. Mr. Coffman?
Mr. Coffman. Thank you, Mr. Chairman.
I just want to--I just don't think this is doable. I just--
I think that we're going to undergo the same problem unless we
change. And I get that we plussed up the IPO to try and make a
difference. I just don't think it's going to make enough of a
difference at the end of the day that we are going to be
efficient in terms of resolving this issue of interoperability.
I think we're going to waste more taxpayer dollars in getting
to where we need to go.
I think from day 1, we made a terrible mistake, the prior
administration and continued by this administration in not
saying to both of these major players, the Department of
Defense and the Department of Veterans Affairs, one of you is
in charge, and the other one can have input, and the IPO can
certainly serve as a vehicle for that input. But by not doing
that, we've created this consensus situation where we hope that
it's going to get done, but we don't know that it's going to
get done.
So I would hope that this Committee would take a hard look
at this organizational structure and say whether or not one of
these two agencies ought to be in charge, ought to be the lead
agency, and then let's move forward from there.
I yield back, Mr. Chairman.
Mr. Banks. General Bergman?
Mr. Bergman. Thank you, Mr. Chairman.
Dr. Thompson, you used a phrase that sent chills up my
spine when the question was asked, what do you need, and it
was: more people.
Okay. You didn't know how many, that's okay. But there's
a--at least when I was spending my time in DoD, the answer that
sent chills up a lot of spines then was the answer to every
problem was: Give us more people, more money, more time, and
we'll get you a solution.
So, you know, the point is, I think we really, really,
really--I don't care who does it--we need to get realistic with
the fact that that is not an answer that is going to energize
what it is we're trying to accomplish. Because when you add
more people to a situation, you get a chart, an org chart,
that, as we've already kind of alluded to here, does not feel
like it reports to anybody, or anybody's in charge. And you
spend--waste a lot of time with reorganizing ourselves just
because there's been a little, you know, a little change.
But let me ask you a question. You know, the GAO had
previously recommended that the IPO have authority over budget
and staff, over interagency processes and over decision-making
for interoperability in both Departments. VA and DoD accepted
the recommendations but never really implemented them. We know
that. It seems that the IPO itself is not able to implement
such recommendations. Is it a lack of authority to exercise
more authority? Who can implement whatever recommendations are
out there?
Ms. Thompson. I joined the IPO in 2015. Those
recommendations were made prior to my tenure with the IPO. So I
can't speak specifically to the reasons why, at that time,
those recommendations were not put into place. As we've been
rechartered, we have a much smaller footprint, very much
focused on health data standards and interoperability, and
that's where we have been focused. If there's a decision made
that the IPO should take on a different function, I think we
would need to consider what it would take for us to perform
that function.
I don't believe today we are configured to support a single
point of accountability as is being suggested here today. We
would be happy to step into that role. I don't believe we're
positioned for it properly today.
Mr. Bergman. So let's say for the sake of discussion that
we had folks like the Under Secretary of Defense for
Acquisition, Technology, and Logistics, AT&L, and ultimately
maybe the Secretary of Defense and maybe the Secretary of
Veterans Affairs and the Deputy Secretary for Veterans Affairs,
do you think if we got them in the room, knowing some of the
personalities involved with that group, that they could come
out with an org chart that would show responsibility for what
actions? I mean, do we have to leave it to the heads to send a
wire diagram down, or I mean, can that actually be done at your
level in a prioritized manner?
Ms. Thompson. We would be happy to do that if that is asked
of us.
Mr. Bergman. Okay, in other words, so if basically told to
do something, you'll do it?
Ms. Thompson. Yes, sir.
Mr. Bergman. Okay, well, I guess we need to figure out--
yeah, yeah. So--yeah. In fact, the doctor and I are practicing
the vulcan mind meld here, because my next question was, Ms.
Harris, what do you think?
Ms. Harris. As currently chartered and resourced, the
office would not be able to function as an effective means for
joint governance. So things would have to change, both in terms
of staffing and resources.
However, in addition, I think the root cause of why the IPO
has been ineffective over the past decade is because it has had
no authority or influence over the actions of the large and
powerful organizations within DoD and VA that have
responsibility for the Departments' electronic health record
programs.
Mr. Bergman. Okay, thank you.
And, Mr. Chairman, I'll yield back the rest of my time.
Mr. Banks. Thank you.
I have one final brief question, which I will ask, and then
I will defer to my colleagues on the Committee if they, too,
might have a brief question before we conclude.
Dr. Thompson, I recently visited the Seattle VA Medical
Center, as you already know. I learned that personnel there had
not been able to visit the nearby military health system
facilities where Cerner has been implemented. It is my
understanding, though, that they will now be permitted to do
that. Is that correct?
Ms. Thompson. Yes, that--that is correct.
Mr. Banks. Okay, thank you.
Do any of my colleagues--Ranking Member Lamb? Dr. Roe?
Mr. Roe. One very quick.
Ms. Harris, as we discussed this governance structure, do
you think there should be one person, one entity, where the
buck stops?
Ms. Harris. Yes, sir.
Mr. Roe. Okay, thank you.
I yield back.
Mr. Banks. Anybody else?
Okay. Well, thank you once again to our witnesses for your
testimony. If there are no further questions, the panel is now
excused.
This afternoon, we have heard a great deal about leadership
and governance. The VA needs leaders to establish the
governance, but the governance must be enduring because
individual leaders will come and go. Unfortunately, we have
seen far too much of that turnover in the early months of this
program. The IPO, or the Interagency Program Office, is one of
the few aspects of her modernization that is mandated by law.
That means that it has a very important and permanent role to
play in governance.
Most everyone here today agrees the IPO needs to do more.
My hope is DoD and VA will hash out what that looks like and
come to mutual agreement. I am willing to give them additional
time to do that, but I will not wait forever. The key decisions
that will determine her modernization's future and prospects
for success are being made over the next several months. I am
skeptical of Congress imposing solutions, but we also have to
keep the train safe on the tracks.
Thank you to all of you again for your participation in
today's hearing.
I'd also like to thank the staff for helping make this a
very productive first hearing of this Subcommittee.
I ask unanimous consent that all Members have 5 legislative
days to revise and extend their remarks and include extraneous
material.
And, without objection, so ordered.
The hearing is now adjourned.
[Whereupon, at 3:22 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Dr. Lauren Thompson
Chairman Banks, Ranking Member Lamb, and distinguished Members of
the Subcommittee, thank you for the opportunity to testify before you
today. I am honored to represent the Department of Defense (DoD) as the
Director of the DoD/Veterans Affairs (VA) Interagency Program Office
(IPO).The mission of the DoD/VA IPO is to lead and coordinate the
adoption of and contribution to national health data standards to
ensure health data interoperability among DoD, VA, and private sector
healthcare worldwide. To give you a bit of history about the IPO, the
Fiscal Year 2008 National Defense Authorization Act (NDAA) directed the
DoD and VA to develop and implement electronic health record (EHR)
systems or capabilities that allow for full interoperability of
personal health care information between the DoD and the VA and
directed the establishment of the IPO to guide both Departments in
their efforts. In January 2009, the IPO completed its first charter,
sharing its mission and functions with respect to attaining
interoperable electronic health data. In March 2011, both secretaries
of Defense and VA instructed the DoD and VA to develop a single,
jointly integrated electronic health record.
When the Departments decided to pursue the modernization of
individual systems in 2014, the DoD decided to replace its older system
by purchasing a new, commercial off-the-shelf solution and the VA
decided to modernize its existing Veterans Health Information Systems
and Technology Architecture (VistA) health information system. In
December 2013, the IPO was rechartered to lead the efforts of the DoD
and VA to implement national health data standards for interoperability
and to establish, monitor, and approve clinical and technical standards
for the integration of health data between both Departments and the
private sector.
INTEROPERABILITY AND DATA SHARING
The DoD and VA represent two of our nation's largest healthcare
systems. Currently, the Departments share more than 1.5 million data
elements daily, and more than 415,000 DoD and VA clinicians are able to
view the real-time records of the more than 16 million patients who
have received care from both Departments.
Providing high-quality healthcare to service members, veterans, and
their families is one of the IPO's highest priorities, and health data
interoperability is essential to improving the care delivered. In April
2016 the Departments, with the IPO's help, met a requirement of the
Fiscal Year 2014 NDAA, certifying to Congress that their systems are
interoperable with an integrated display of data. While the Departments
met the required objectives, interoperability is a spectrum wherein
data sharing and functionality can continually improve.
The two Departments currently share health records through the
Defense Medical Information Exchange (DMIX) program, which includes the
Joint Legacy Viewer, a health information portal that aggregates data
from across multiple data sources to provide read access to medical
information across multiple government and commercial data sources. As
a result, the Departments increased patient data accessed through Joint
Legacy Viewer more than fivefold; including the over 1.5 million data
elements shared daily between the DoD and VA combined.
COLLABORATIVE DATA STANDARDS
Today, working closely with the Office of the National Coordinator
for Health Information Technology (ONC) and standards development
organizations, the IPO supports the identification, implementation, and
evolution of the national standards associated with both Departments'
Electronic Health Records. These activities are vital to continue
providing the building blocks necessary for the Departments to expand
and improve their health data interoperability, both across the
Departments and with private healthcare providers.
The IPO is a collaborative entity, comprised of approximately 30
staff members from both the DoD and VA who have technical expertise in
health data standards and information sharing.
Assisting the Departments with their interoperability and
Electronic Health Record modernization milestones, the IPO serves as a
central resource for the DoD and VA as they develop, adopt, and update
a technical framework that is clinically driven to align identified
standards with approved use cases. To that end, the IPO monitors
industry best practices and provides technical guidance to facilitate
health data exchange between the Departments and with private
healthcare providers. The IPO also serves as a conduit for the
Departments' engagement with the Office of the National Coordinator for
Health Information Technology and standards development organizations
to facilitate knowledge sharing on a national level. The IPO is
integrated into the Office of the National Coordinator for Health
Information Technology's planning for a national health IT ecosystem
and is a key contributor to the Office of the National Coordinator for
Health Information Technology's Interoperability Standards Advisory, a
process that identifies standards to advance nationwide Health IT
interoperability.
METRICS MONITORING
The IPO also plays an important role in monitoring DoD and VA
interoperability efforts.
Specifically, the IPO established a Health Data Interoperability
Metrics Dashboard to identify Department-specific targets for
transactional metrics and trends, routinely shared with Congress.
In addition to these efforts, and in conjunction with the
Departments, the IPO implemented the Government Accountability Office's
(GAO) recommendations that the DoD and VA adopt outcome-oriented
metrics to provide a basis for assessing and reporting on the health
data interoperability progress, which resulted in the DoD/VA IPO Health
Outcome-Oriented Metrics Roadmap. The IPO continues to foster the
development of metrics in collaboration with the Health Executive
Committee's Health Data Sharing Business Line sub-workgroups, based on
the Joint Interoperability Strategic Plan use cases, developing metrics
for Separating Service Members and Integrated Disability Evaluation
System, Patient Empowerment, Transitions of Care, and Population
Health.
ELECTRONIC HEALTH RECORD COLLABORATION
In July 2015, the DoD awarded a contract to the Leidos Inc. to
deliver a modern, secure, and connected Electronic Health Record. The
Leidos Partnership for Defense Health team consists of four core
partners, Leidos Inc., as the prime integrator, and three primary
partners in Cerner Corporation, Accenture, and Henry Schein Inc. The
commercial electronic health record system, MHS GENESIS, provides a
state of the market commercial off the shelf solution.
Throughout 2017, the DoD achieved major milestones, deploying MHS
GENESIS to Fairchild Air Force Base, Naval Health Clinic Oak Harbor,
Naval Hospital Bremerton, and Madigan Army Medical Center, all in the
state of Washington. The DoD plans to deploy MHS GENESIS to more than
9.4 million beneficiaries and 205,000 medical personnel and staff by
the end of 2023.
In June 2017, VA announced its plans to adopt the same Electronic
Health Record system as the DoD, and on May 17, 2018, VA signed a
contract with Cerner Corporation. Both Departments using the same
electronic health record system will ultimately result in a single
software baseline and enable seamless care between them without the
exchange and reconciliation of data between two separate systems. This
decision will, over time, solve the problem of moving patient health
record data between the Departments, as there will be a single, common
clinical system. This decision is another step toward advancing
Electronic Health Record adoption across the nation and is in the best
interest of our service members, veterans, and their families.
The VA and DoD are committed to partnering in this effort and
understand that the mutual success of this venture is dependent on the
close coordination and communication between the two Departments. As a
result, the IPO's role in facilitating collaboration between the DoD
and VA is more vital than ever before. The IPO has been actively
supporting the Departments with the development of a governance process
to enable them to make joint decisions regarding common aspects of the
Electronic Health Record solution. This process will involve multiple
layers, from Department-level governance within the DoD and VA, to the
interagency coordination and collaboration through working groups and
committees that is already underway and facilitated by the IPO, to
joint DoD/VA Electronic Health Record Modernization governance bodies.
We expect these governance bodies to be in place by 2019.
The joint Electronic Health Record Modernization governance bodies
will focus on adjudicating only those issues that cannot be agreed upon
through the existing interagency structures. The IPO will support the
governance process, host meetings, manage information collection, and
communicate assessments, meeting materials, action items, and
decisions. The IPO will provide expertise and guidance implementing
best practices and ensure a common standard operating procedure for
capturing the artifacts needed to support decision-making by the
Electronic Health Record Modernization governance bodies. The IPO will
also be responsible for managing, organizing, and communicating
decisions made by the governance bodies. However, the IPO will not
redefine Departmental processes or function as a decision authority.
CONCLUSION
The field of health data is constantly evolving. With the DoD and
VA further enhancing interoperability through the implementation of the
same Electronic Health Record, the IPO must continue collaboration with
the Office of the National Coordinator for Health Information
Technology and industry partners to ensure that the DoD and VA map
their data to the latest national standards, and that the Office of the
National Coordinator for Health Information Technology and the private
sector can continue to learn from our experience.
The IPO is fully committed to assisting the DoD and VA as they
continue their modernization.
Enabling health information exchange between systems in DoD, VA,
and the private sector will serve as the foundation for a patient-
centric healthcare experience, seamless care transitions, and improved
care for our service members, veterans, and their families.
Again, thank you for this opportunity, and I look forward to your
questions.
------
Prepared Statement of Carol C. Harris
ELECTRONIC HEALTH RECORDS
Clear Definition of the Interagency Program Office's Role in VA's New
Modernization Effort Would Strengthen Accountability
Chairman Banks, Ranking Member Lamb, and Members of the
Subcommittee:
Thank you for the opportunity to participate in today's hearing on
the Department of Defense (DoD) and Department of Veterans Affairs (VA)
Interagency Program Office and the office's role regarding VA's
Electronic Health Record Modernization (EHRM) program. As you know,
these departments operate two of the nation's largest health care
systems, which provide coverage to millions of veterans and active duty
service members and their beneficiaries. The use of information
technology (IT) is crucial to helping the departments effectively serve
the nation's veterans and, each year, the departments spend billions of
dollars on information systems and assets.
Both VA and DoD have long recognized the importance of advancing
the use of shared health information systems and capabilities to make
patient information more readily available to their health care
providers, reduce medical errors, and streamline administrative
functions. Toward this end, the two departments have an extensive
history of working to achieve shared health care resources. \1\ Over
many years, however, the departments have experienced challenges in
managing a number of critical initiatives related to modernizing major
systems. Such initiatives include modernizing VA's electronic health
information system--the Veterans Health Information Systems and
Technology Architecture (VistA).
---------------------------------------------------------------------------
\1\ Since the 1980s, VA and DoD have entered into many types of
collaborations to provide health care services-including emergency,
specialty, inpatient, and outpatient care-to VA and DoD beneficiaries,
reimbursing each other for the services provided. These collaborations
vary in scope, ranging from agreements to jointly provide a single type
of service to more coordinated "joint ventures," which encompass
multiple health care services and facilities and focus on mutual
benefit, shared risk, and joint operations in specific clinical areas.
---------------------------------------------------------------------------
To expedite the departments' efforts to exchange electronic health
care information, Congress included in the National Defense
Authorization Act for Fiscal Year 2008, provisions that required VA and
DoD to jointly develop and implement electronic health record systems
or capabilities and to accelerate the exchange of health care
information. \2\ The act also required that these systems or
capabilities be compliant with applicable interoperability \3\
standards, implementation specifications, and certification criteria of
the federal government.
---------------------------------------------------------------------------
\2\ Pub. L. No. 110-181, Sec. 1635, 122 Stat. 3, 460-463 (2008).
\3\ According to the National Defense Authorization Act for Fiscal
Year 2014, interoperability is the ability of different electronic
health records systems or software to meaningfully exchange information
in real time and provide useful results to one or more systems. See
Pub. L. No. 113-66, Div. A, Title VII, Sec. 713, 127 Stat. 672, 794-
798 (Dec. 26, 2013).
---------------------------------------------------------------------------
Further, the act established a joint Interagency Program Office to
act as a single point of accountability for the electronic health care
exchange efforts. The office was given the function of implementing, by
September 30, 2009, electronic health record systems or capabilities
that would allow for full interoperability of personal health care
information between the departments.
In addition, the act included a provision that GAO report on the
progress that VA and DoD have made in achieving the goal of fully
interoperable personal health care information. Our reports in response
to this requirement included information on the departments' efforts to
set up the joint Interagency Program Office. \4\ We also subsequently
produced reports that have discussed the Interagency Program Office in
relation to VA's efforts to develop a lifetime electronic health record
capability for servicemembers and veterans, \5\ develop a joint
electronic record capability with DoD \6\, and promote increased
electronic health record system interoperability. \7\
---------------------------------------------------------------------------
\4\ GAO, Electronic Health Records: DoD and VA Have Increased Their
Sharing of Health Information, but More Work Remains, GAO-08-954
(Washington, D.C.: July 28, 2008); Electronic Health Records: DoD's and
VA's Sharing of Information Could Benefit from Improved Management,
GAO-09-268 (Washington, D.C.: Jan. 28, 2009); Electronic Health
Records: DoD and VA Efforts to Achieve Full Interoperability Are
Ongoing; Program Office Management Needs Improvement, GAO-09-775
(Washington, D.C.: July 28, 2009); and Electronic Health Records: DoD
and VA Interoperability Efforts Are Ongoing; Program Office Needs to
Implement Recommended Improvements, GAO-10-332 (Washington, D.C.: Jan.
28, 2010).
\5\ GAO, Electronic Health Records: DoD and VA Should Remove
Barriers and Improve Efforts to Meet Their Common System Needs, GAO-11-
265 (Washington, D.C.: Feb. 2, 2011).
\6\ GAO, Electronic Health Records: VA and DoD Need to Support Cost
and Schedule Claims, Develop Interoperability Plans, and Improve
Collaboration, GAO-14-302 (Washington, D.C.: Feb 27, 2014).
\7\ GAO, Electronic Health Records: Outcome-Oriented Metrics and
Goals Needed to Gauge DoD's and VA's Progress in Achieving
Interoperability, GAO-15-530 (Washington, D.C.: Aug 13, 2015).
---------------------------------------------------------------------------
At your request, my testimony today summarizes findings from our
prior work that examined the establishment and evolution of the
Interagency Program Office over the last decade. The testimony also
discusses the roles this office has played in VA's and DoD's efforts to
increase interoperability and electronic health record capabilities,
and any challenges the office has faced in doing so.
In developing this testimony, we relied on our previous reports and
testimonies related to the Interagency Program Office, as well as VA's
and DoD's electronic health record system programs and modernization
efforts. \8\ We also incorporated information on the departments'
actions in response to recommendations we made in our previous reports.
In addition, we discussed this testimony with the Executive Director of
VA's EHRM office. The reports cited throughout this statement include
detailed information on the scope and methodology of our prior reviews.
---------------------------------------------------------------------------
\8\ GAO, VA IT Modernization: Preparations for Transitioning to a
New Electronic Health Record System Are Ongoing, GAO-18-636T
(Washington, D.C.: June 26, 2018); VA Health IT Modernization:
Historical Perspective on Prior Contracts and Update on Plans for New
Initiative, GAO-18-208 (Washington, D.C.: Jan. 18, 2018); Electronic
Health Records: VA's Efforts Raise Concerns about Interoperability
Goals and Measures, Duplication with DoD, and Future Plans, GAO-16-807T
(Washington, D.C.: July 13, 2016); GAO-15-530; GAO-14-302; Electronic
Health Records: Long History of Management Challenges Raises Concerns
about VA's and DoD's New Approach to Sharing Health Information, GAO-
13-413T (Washington, D.C.: Feb 27, 2013); GAO-11-265; GAO-10-332; GAO-
09-775; GAO-09-268; and GAO-08-954.
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We conducted the work on which this statement is based in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Background
Historically, patient health information has been scattered across
paper records kept by many different caregivers in many different
locations, making it difficult for a clinician to access all of a
patient's health information at the time of care. Lacking access to
these critical data, a clinician may be challenged in making the most
informed decisions on treatment options, potentially putting the
patient's health at risk.
The use of technology to electronically collect, store, retrieve,
and transfer clinical, administrative, and financial health information
has the potential to improve the quality and efficiency of health care.
Electronic health records are particularly crucial for optimizing the
health care provided to military personnel and veterans. While in
active military status and later as veterans, many DoD and VA
personnel, along with their family members, tend to be highly mobile
and may have health records residing at multiple medical facilities
within and outside the United States.
VA and DoD operate separate electronic health record systems that
they rely on to create and manage patient health information. In
particular, VA currently uses its integrated medical information
system--VistA--which was developed in-house by the department's
clinicians and IT personnel and has been in operation since the early
1980s. \9\ Over the last several decades, VistA has evolved into a
technically complex system comprised of about 170 modules that support
health care delivery at 170 VA Medical Centers and over 1,200
outpatient sites. In addition, customization of VistA, such as changes
to the modules by the various medical facilities, has resulted in about
130 versions of the system--referred to as instances.
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\9\ VistA began operation in 1983 as the Decentralized Hospital
Computer Program. In 1996, the name of the system was changed to VistA.
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For its part, DoD relies on its Armed Forces Health Longitudinal
Technology Application (AHLTA), which comprises multiple legacy medical
information systems that were developed from commercial software
products and customized for specific uses. For example, the Composite
Health Care System (CHCS), which was formerly DoD's primary health
information system, is used to capture information related to pharmacy,
radiology, and laboratory order management. In addition, the department
uses Essentris (also called the Clinical Information System), a
commercial health information system customized to support inpatient
treatment at military medical facilities.
In July 2015, DoD awarded a contract for a new commercial
electronic health record system to be developed by the Cerner
Corporation. Known as MHS GENESIS, this system is intended to replace
DoD's existing AHLTA system. The transition to MHS GENESIS began in
February 2017 and implementation is expected to be complete throughout
the department in 2022.
Interoperability: An Overview
The sharing of health information among organizations is especially
important because the health care system is highly fragmented, with
care and services provided in multiple settings, such as physician
offices and hospitals, that may not be able to coordinate patient
medical care records. Thus, a means for sharing information among
providers, such as between DoD's and VA's health care systems, is by
achieving interoperability.
The Office of the National Coordinator for Health IT, \10\ within
the Department of Health and Human Services, has issued guidance, \11\
describing interoperability as:
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\10\ The Office of the National Coordinator for Health IT is
responsible for overseeing the certification of electronic health
record technology, including establishing technical standards and
certification criteria for it. Additionally, the Office of the National
Coordinator is charged with formulating the federal government's health
IT strategy and coordinating related policies, programs, and
investments.
\11\ Office of the National Coordinator for Health IT, Connecting
Health and Care for the Nation: A Shared Nationwide Interoperability
Roadmap Final Version 1.0. The definition of interoperability used in
the Roadmap is derived from the Institute of Electrical and Electronics
Engineers definition of interoperability.
1.the ability of systems to exchange electronic health information
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and
2. the ability to use the electronic health information that has
been exchanged from other systems without special effort on the part of
the user.
Similarly, the National Defense Authorization Act for Fiscal Year
2014 \12\ defines interoperability, per its use in the provision
governing VA's and DoD's electronic health records, as ``the ability of
different electronic health records systems or software to meaningfully
exchange information in real time and provide useful results to one or
more systems.'' Thus, in these contexts, interoperability allows
patients' electronic health information to be available from provider
to provider, regardless of where the information originated.
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\12\ Pub. L. No. 113-66, Div. A, Title VII, Sec. 713, 127 Stat.
672, 794-798 (Dec. 26, 2013).
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Achieving interoperability depends on, among other things, the use
of agreed-upon health data standards \13\ to ensure that information
can be shared and used. If electronic health records conform to
interoperability standards, they potentially can be created, managed,
and consulted by authorized clinicians and staff across more than one
health care organization, thus providing patients and their caregivers
the information needed for optimal care. Information that is
electronically exchanged from one provider to another must adhere to
the same standards in order to be interpreted and used in electronic
health records, thereby permitting interoperability. \14\
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\13\ Health data standards are one component that can be used to
facilitate health information exchange and interoperability. Such
standards consist of languages and technical specifications that, when
adopted by multiple entities, facilitate the exchange of health
information. Health data standards include, for example, standardized
language for prescriptions and for laboratory testing.
\14\ GAO, Electronic Health Records: HHS Strategy to Address
Information Exchange Challenges Lacks Specific Prioritized Actions and
Milestones, GAO-14-242 (Washington, D.C.: Mar. 24, 2014); and
Electronic Health Record Programs: Participation Has Increased, but
Action Needed to Achieve Goals, Including Improved Quality of Care,
GAO-14-207 (Washington, D.C.: Mar. 6, 2014).
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In the health IT field, standards may govern areas ranging from
technical issues, such as file types and interchange systems, to
content issues, such as medical terminology. \15\ On a national level,
the Office of the National Coordinator has been assigned responsibility
for identifying health data standards and technical specifications for
electronic health record technology and overseeing the certification of
this technology.
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\15\ Developing, coordinating, and agreeing on standards are only
parts of the processes involved in achieving interoperability for
electronic health records systems or capabilities. In addition,
specifications are needed for implementing the standards.
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In addition to exchanging the information, systems must be able to
use the information that is exchanged. Thus, if used in a way that
improves providers' and patients' access to critical information,
electronic health record technology has the potential to improve the
quality of care that patients receive and to reduce health care costs.
For example, with interoperability, medical providers have the ability
to query data from other sources while managing chronically ill
patients, regardless of geography or the network on which the data
reside.
VA and DoD Have a Long History of Efforts to Achieve Electronic Health
Record Interoperability
Since 1998, DoD and VA have relied on a patchwork of initiatives
involving their health information systems to exchange information and
increase electronic health record interoperability. These have included
initiatives to share viewable data in existing (legacy) systems; link
and share computable data between the departments' updated health data
repositories; develop a virtual lifetime electronic health record to
enable private sector interoperability; implement IT capabilities for
the first joint federal health care center; and jointly develop a
single integrated system. Table 1 provides a brief description of the
history of these various initiatives.
[GRAPHIC] [TIFF OMITTED] T5832.001
In addition to the initiatives mentioned in table 1, DoD and VA
previously responded to provisions in the National Defense
Authorization Act for Fiscal Year 2008 directing the departments to
jointly develop and implement fully interoperable electronic health
record systems or capabilities in 2009. \16\ The act also called for
the departments to set up the Interagency Program Office to be a single
point of accountability for their efforts to implement these systems or
capabilities by the September 30, 2009, deadline.
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\16\ Pub. L. No. 110-181, Sec. 1635, 122 Stat. 3, 460-463 (2008).
The Interagency Program Office Has Not Functioned as the Single Point
of Accountability for VA and DoD's Efforts to Increase Electronic
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Health Record Interoperability
The Interagency Program Office has been involved in the various
approaches taken by VA and DoD to increase health information
interoperability and modernize their respective electronic health
record systems. These approaches have included development of the
Virtual Lifetime Electronic Record (VLER) and a new, common integrated
electronic health record (iEHR) system. However, although the
Interagency Program Office has led efforts to identify data standards
that are critical to interoperability between systems, the office has
not been effectively positioned to be the single point of
accountability as called for in the National Defense Authorization Act
for Fiscal Year 2008. Moreover, the future role of the office with
respect to VA's current electronic health record modernization program
is uncertain.
The Interagency Program Office Became Operational, but Was Not
Positioned to Be the Single Point of Accountability for Achieving
Interoperability
Although VA and DoD took steps to set up the Interagency Program
Office, the office was not positioned to be the single point of
accountability for the departments' efforts to achieve electronic
health record interoperability by September 30, 2009. When we first
reported on its establishment in July 2008, VA and DoD's efforts to set
up the office were still in their early stages. \17\ Leadership
positions in the office were not yet permanently filled, staffing was
not complete, and facilities to house the office had not been
designated. Further, the implementation plan for setting up the office
was in draft and, although the plan included schedules and milestones,
the dates for several activities (such as implementing a capability to
share immunization records) had not yet been determined, even though
all capabilities were to be achieved by September 2009.
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\17\ GAO-08-954.
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We concluded that without a fully established program office and a
finalized implementation plan with set milestones, the departments
could be challenged in meeting the required date for achieving
interoperability. Accordingly, we recommended that the departments give
priority to fully establishing the office by putting in place permanent
leadership and staff, as well as finalizing the draft implementation
plan. Both departments agreed with this recommendation.
We later reported in January 2009 that VA and DoD had continued to
take steps to set up the Interagency Program Office. \18\ For example,
the departments had developed descriptions for key positions within the
office. In addition, the departments had developed a document that
depicted the Interagency Program Office's organizational structure;
they also had approved a program office charter to describe, among
other things, the mission and functions of the office.
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\18\ GAO-09-268.
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However, we pointed out that VA and DoD had not yet fully executed
their plan to set up the office. For example, among other activities,
they had not filled key positions for the Director and Deputy Director,
or for 22 of 30 other positions identified for the office.
Our report stressed that, in the continued absence of a fully
established Interagency Program Office, the departments would remain
ineffectively positioned to assure that interoperable electronic health
records and capabilities would be achieved by the required date. Thus,
we recommended that the departments develop results-oriented
performance goals and measures to be used as the basis for reporting
interoperability progress. VA and DoD agreed with our recommendation.
Nevertheless, in a subsequent July 2009 report, we noted that the
Interagency Program Office was not effectively positioned to function
as a single point of accountability for the implementation of fully
interoperable electronic health record systems or capabilities between
VA and DoD. \19\ While the departments had made progress in setting up
the office by hiring additional staff, they continued to fill key
leadership positions on an interim basis. Further, while the office had
begun to demonstrate responsibilities outlined in its charter, it was
not yet fulfilling key IT management responsibilities in the areas of
performance measurement (as we previously recommended), project
planning, and scheduling, which were essential to establishing the
office as a single point of accountability for the departments'
interoperability efforts. Thus, we recommended that the departments
improve the management of their interoperability efforts by developing
a project plan and a complete and detailed integrated master schedule.
VA and DoD stated that they agreed with this recommendation.
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\19\ GAO-09-775.
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In our January 2010 final report in response to the National
Defense Authorization Act for Fiscal Year 2008, we noted that VA and
DoD officials believed they had satisfied the act's September 30, 2009,
requirement for full interoperability by meeting specific
interoperability-related objectives that the departments had
established. \20\ These objectives included: refine social history
data, share physical exam data, and demonstrate initial document
scanning between the departments.
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\20\ GAO-10-332.
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Additionally, the departments had made progress in setting up their
Interagency Program Office by hiring additional staff, including a
permanent director. In addition, consistent with our recommendations in
the three previously mentioned reports, the office had begun to
demonstrate responsibilities outlined in its charter in the areas of
scheduling, planning, and performance measurement.
Nevertheless, the office's efforts in these areas did not fully
satisfy the recommendations and were incomplete. Specifically, the
office did not have a schedule that included information about tasks,
resource needs, or relationships between tasks associated with ongoing
activities to increase interoperability. Also, key IT management
responsibilities in the areas of planning and performance measurement
remained incomplete. We reiterated that, by not having fulfilled key
management responsibilities, as we had previously recommended, the
Interagency Program Office continued to not be positioned to function
as a single point of accountability for the delivery of the future
interoperable capabilities that the departments were planning.
The Interagency Program Office Was to Be the Single Point of
Accountability for Establishing a Lifetime Electronic Record for
Servicemembers and Veterans, but VA and DoD Did Not Develop
Complete Plans for the Effort
Although the Interagency Program Office charter named the office as
the single point of accountability for the initiative, the office did
not have key plans to define and guide the effort. In April 2009, the
President announced that VA and DoD would work together to define and
build VLER to streamline the transition of electronic medical,
benefits, and administrative information between the two departments.
VLER was intended to enable access to all electronic records for
service members as they transition from military to veteran status, and
throughout their lives. Further, the initiative was to expand the
departments' health information sharing capabilities by enabling access
to private sector health data.
Shortly after the April 2009 announcement, VA, DoD, and the
Interagency Program Office began working to define and plan for the
VLER initiative. Further, the office was rechartered in September 2009
and named as the single point of accountability for the coordination
and oversight of jointly approved IT projects, data, and information
sharing activities, including VLER.
In our February 2011 report on the departments' efforts to address
their common health IT needs, we noted that, among other things, the
Interagency Program Office had not developed an approved integrated
master schedule, master program plan, or performance metrics for the
VLER initiative, as outlined in the office's charter. \21\ We noted
that if the departments did not address these issues, their ability to
effectively deliver capabilities to support their joint health IT needs
would be uncertain. Thus, we recommended that the Secretaries of VA and
DoD strengthen their efforts to establish VLER by developing plans that
would include scope definition, cost and schedule estimation, and
project plan documentation and approval. Although the departments
stated they agreed with this recommendation, they did not implement it.
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\21\ GAO-11-265.
The Interagency Program Office Was Responsible for the Development of a
Joint Electronic Health Record System for VA and DoD, but the
---------------------------------------------------------------------------
Office Was Not Positioned for Effective Collaboration
The Interagency Program Office was assigned responsibility for the
development of an electronic health record system that VA and DoD were
to share. However, the departments did not provide the office with
control over the resources (i.e., funds and staff) it needed to
facilitate effective collaboration.
In March 2011, the Secretaries of VA and DoD committed the two
departments to developing the iEHR system, and in May 2012 announced
their goal of implementing it across the departments by 2017. To
oversee this new effort, in October 2011, VA and DoD re-chartered the
Interagency Program Office to give it increased authority, expanded
responsibilities, and increased staffing levels for leading the
integrated system effort. The new charter also gave the office
responsibility for program planning and budgeting, acquisition and
development, and implementation of clinical capabilities. However, in
February 2013, the Secretaries of VA and DoD announced that they would
not continue with their joint development of a single electronic health
record system.
In February 2014, we reported on the departments' decision to
abandon their plans for iEHR. \22\ Specifically, we reported that VA
and DoD had not addressed management barriers to effective
collaboration on their joint health IT efforts. For example, the
Interagency Program Office was intended to better position the
departments to collaborate, but the departments had not implemented the
office in a manner consistent with effective collaboration.
Specifically, the Interagency Program Office lacked effective control
over essential resources such as funding and staffing. In addition,
decisions by the departments had diffused responsibility for achieving
integrated health records, potentially undermining the office's
intended role as the single point of accountability.
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\22\ GAO-14-302.
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We concluded that providing the Interagency Program Office with
control over essential resources and clearer lines of authority would
better position it for effective collaboration. Further, we recommended
that VA and DoD better position the office to function as the single
point of accountability for achieving interoperability between the
departments' electronic health record systems by ensuring that the
office has authority (1) over dedicated resources (e.g., budget and
staff), (2) to develop interagency processes, and (3) to make decisions
over the departments' interoperability efforts. Although VA and DoD
stated that they agreed with this recommendation, they did not
implement it.
The Interagency Program Office Subsequently Took Steps to Improve
Interoperability Measurement and Additional Actions Are Planned
In light of the departments' not having implemented a solution that
allowed for seamless electronic sharing of medical health care data,
the National Defense Authorization Act for Fiscal Year 2014 included
requirements pertaining to the implementation, design, and planning for
interoperability between VA and DoD's separate electronic health record
systems. Among other things, the departments were each directed to (1)
ensure that all health care data contained in VA's VistA and DoD's
AHLTA systems complied with national standards and were computable in
real time by October 1, 2014, and (2) deploy modernized electronic
health record software to support clinicians while ensuring full
standards-based interoperability by December 31, 2016.
In August 2015, we reported that VA and DoD, with guidance from the
Interagency Program Office, had taken actions to increase
interoperability between their electronic health record systems. \23\
Among other things, the departments had initiated work focused on near-
term objectives, including standardizing their existing health data and
making them viewable by both departments' clinicians in an integrated
format. The departments also developed longer-term plans to modernize
their respective electronic health record systems. For its part, the
Interagency Program Office issued guidance outlining the technical
approach for achieving interoperability between the departments'
systems.
---------------------------------------------------------------------------
\23\ GAO-15-530.
---------------------------------------------------------------------------
However, even with the actions taken, VA and DoD did not certify by
the October 1, 2014, deadline established in the National Defense
Authorization Act for Fiscal Year 2014 for compliance with national
data standards that all health care data in their systems complied with
national standards and were computable in real time.
We also reported that the departments' system modernization plans
identified a number of key activities to be implemented beyond December
31, 2016--the deadline established in the act for the two departments
to deploy modernized electronic health record software to support
clinicians while ensuring full standards-based interoperability.
Specifically, DoD had issued plans and announced the contract award for
acquiring a modernized system to include interoperability capabilities
across military operations. VA had issued plans describing an
incremental approach to modernizing its existing electronic health
records system. These plans--if implemented as described--indicated
that deployment of the new systems with interoperability capabilities
would not be completed across the departments until after 2018.
With regard to its role, the Interagency Program Office had taken
steps to develop process metrics intended to monitor progress related
to the data standardization and exchange of health information
consistent with its responsibilities. For example, it had issued
guidance that calls for tracking metrics, such as the percentage of
data domains within the departments' current health information systems
that are mapped to national standards.
However, the office had not yet specified outcome-oriented metrics
and established related goals that are important to gauging the impact
that interoperability capabilities have on improving health care
services for shared patients. As a result, we recommended that VA and
DoD, working with the Interagency Program Office, take actions to
establish a time frame for identifying outcome-oriented metrics, define
goals to provide a basis for assessing and reporting on the status of
interoperability-related activities and the extent to which
interoperability is being achieved by the departments' modernized
electronic health record systems, and update Interagency Program Office
guidance to reflect the metrics and goals identified.
Subsequently, we reported that VA and DoD had certified in April
2016 that all health care data in their systems complied with national
standards and were computable in real time. \24\ However, VA
acknowledged that it did not expect to complete a number of key
activities related to its electronic health record system until
sometime after the December 31, 2016, statutory deadline for deploying
modernized electronic health record software with interoperability.
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\24\ GAO-16-807T.
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Further, in following up on implementation of the recommendations
in our August 2015 report, we found that VA, DoD, and the Interagency
Program Office had addressed the recommendations in full by updating
guidance to include goals and objectives and an approach to developing
metrics that would improve the departments' ability to report on the
status of interoperability activities.
The Interagency Program Office's Role in Governing VA's New Electronic
Health Record System Acquisition Is Uncertain
In June 2017, the former VA Secretary announced a significant shift
in the department's approach to modernizing the department's electronic
health record system. Specifically, rather than continue to use VistA,
the Secretary stated that the department planned to acquire the same
Cerner electronic health record system that DoD has been acquiring.
\25\
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\25\ In July 2015, DoD awarded a $4.3 billion contract for a
commercial electronic health record system developed by Cerner, to be
known as MHS GENESIS. The transition to the new system began in
February 2017 in the Pacific Northwest region of the United States and
is expected to be completed in 2022. The former Secretary of Veterans
Affairs signed a "Determination and Findings," to justify use of the
public interest exception to the requirement for full and open
competition, and authorized VA to issue a solicitation directly to
Cerner. A "Determination and Findings" means a special form of written
approval by an authorized official that is required by statute or
regulation as a prerequisite to taking certain contract actions. The
"Determination" is a conclusion or decision supported by the
"Findings.'' The findings are statements of fact or rationale essential
to support the determination and must cover each requirement of the
statute or regulation. FAR, 48 C.F.R. Sec. 1.701.
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Accordingly, the department awarded a contract to Cerner in May
2018 for a maximum of $10 billion over 10 years. Cerner is to replace
VistA with a commercial electronic health record system. This new
system is to support a broad range of health care functions that
include, for example, acute care, clinical decision support, dental
care, and emergency medicine. When implemented, the new system will be
expected to provide access to authoritative clinical data sources and
become the authoritative source of clinical data to support improved
health, patient safety, and quality of care provided by VA.
Deployment of the new electronic health record system at three
initial sites is planned for within 18 months of October 1, 2018, \26\
with a phased implementation of the remaining sites over the next
decade. Each VA medical facility is expected to continue using VistA
until the new system has been deployed at that location.
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\26\ The three initial deployment sites are the Mann-Grandstaff,
American Lake, and Seattle VA Medical Centers.
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As we testified in June 2018, VA has taken steps to establish a
program management office and has drafted a structure for technology,
functional, and joint governance of the electronic health record
implementation. \27\ Specifically, in January 2018, the former VA
Secretary established the Electronic Health Record Modernization (EHRM)
program office that reports directly to the VA Deputy Secretary.
---------------------------------------------------------------------------
\27\ GAO-18-636T.
---------------------------------------------------------------------------
Further, VA has drafted a memorandum that describes the role of
governance bodies within VA, as well as governance intended to
facilitate coordination between the department and DoD. According to
EHRM program documentation, VA is in the process of establishing a
Functional Governance Board, a Technical Governance Board, and a
Governance Integration Board comprised of program officials intended to
provide guidance and coordinate with DoD, as appropriate. Further, a
joint governance structure between VA and DoD has been proposed that
would be expected to leverage existing joint governance facilitated by
the Interagency Program Office.
Nevertheless, while VA's plans for governance of the EHRM program
provide a framework for high-level oversight for program decisions
moving forward, EHRM officials have noted that the governance bodies
will not be finalized until October 2018. Accordingly, the officials
have not yet indicated what role, if any, the Interagency Program
Office is to have in the governance process.
Conclusions
The responsibilities of the Interagency Program Office have been
intended to support the numerous approaches taken by VA and DoD to
increase health information interoperability and modernize their
respective electronic health record systems. Yet, while the office has
led key efforts to identify data standards that are critical to
interoperability between systems, the office has not been effectively
positioned to be the single point of accountability originally
described in the National Defense Authorization Act for Fiscal Year
2008. Further, the future role of the Interagency Program Office
remains unclear despite the continuing need for VA and DoD to share the
electronic health records of servicemembers and veterans. In
particular, what role, if any, that the office is to have in VA's
acquisition of the same electronic health record system that DoD is
currently acquiring is uncertain.
Recommendation for Executive Action
We are making the following recommendation to VA:
The Secretary of Veterans Affairs should ensure that the role and
responsibilities of the Interagency Program Office are clearly defined
within the governance plans for acquisition of the department's new
electronic health record system. (Recommendation 1)
Chairman Banks, Ranking Member Lamb, and Members of the
Subcommittee, this completes my prepared statement. I would be pleased
to respond to any questions that you may have at this time.
GAO Contact and Staff Acknowledgments
If you or your staffs have any questions about this testimony,
please contact Carol C. Harris, Director, Information Technology
Acquisition Management Issues, at (202) 512-4456 or [email protected].
Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this testimony statement. GAO
staff who made key contributions to this testimony are Mark Bird
(Assistant Director), Jennifer Stavros-Turner (Analyst in Charge),
Rebecca Eyler, Jacqueline Mai, Scott Pettis, and Charles Youman.
GAO HIGHLIGHTS
What GAO Found
Since its establishment in 2008, the Department of Defense (DoD)
and Department of Veterans Affairs (VA) Interagency Program Office has
been involved in various approaches to increase health information
interoperability. However, the office has not been effectively
positioned to function as the single point of accountability for the
departments' electronic health record system interoperability efforts.
For example,
Between July 2008 and January 2010, GAO issued reports on
VA's and DoD's efforts to set up the office, which highlighted steps
the departments had taken, but also identified deficiencies, such as
vacant leadership positions and a lack of necessary plans. GAO
recommended that the departments improve management of their
interoperability efforts by developing a project plan and results-
oriented performance goals and measures.
In April 2009, the Interagency Program Office was
assigned responsibility for establishing a lifetime electronic record
for servicemembers and veterans, called the Virtual Lifetime Electronic
Record. GAO reported in February 2011 that, among other things, the
office had not developed and approved an integrated master schedule, a
master program plan, or performance metrics for the initiative, as
outlined in the office's charter. Accordingly, GAO recommended that the
departments correct these deficiencies to strengthen their efforts to
establish the Virtual Lifetime Electronic Record.
In March 2011, VA and DoD committed to jointly developing
a new, common integrated electronic health record system and empowered
the Interagency Program Office with increased authority, expanded
responsibilities, and increased staffing levels for leading the
integrated system effort. However, in February 2013, the departments
abandoned their plan to develop the integrated system and stated that
they would again pursue separate modernization efforts. In February
2014, GAO reported on this decision and recommended that VA and DoD
take steps to better position the office to function as the single
point of accountability for achieving interoperability between the
departments' electronic health record systems.
VA and DoD stated that they agreed with the above GAO
recommendations. However, in several cases the departments' subsequent
actions were incomplete and did not fully address all recommendations.
In June 2017 VA announced that it planned to acquire the same
electronic health record system that DoD has been acquiring. GAO
testified in June 2018 that a governance structure had been proposed
that would be expected to leverage existing joint governance
facilitated by the Interagency Program Office. At that time, VA's
program officials had stated that the department's governance plans for
the new program were expected to be finalized in October 2018. However,
the officials have not yet indicated what role, if any, the Interagency
Program Office is to have in the governance process. Ensuring that the
role and responsibilities of the office are clearly defined within
these governance plans is essential to VA successfully acquiring and
implementing the same system as DoD.
View GAO-18-696T. For more information, contact Carol C. Harris at
(202) 512-4456 or [email protected].
Highlights of GAO-18-696T, a testimony before the Subcommittee on
Technology Modernization, Committee on Veterans' Affairs, House of
Representatives
ELECTRONIC HEALTH RECORDS
Clear Definition of the Interagency Program Office's Role in VA's New
Modernization Effort Would Strengthen Accountability
Why GAO Did This Study
The National Defense Authorization Act for Fiscal Year 2008
included provisions that VA and DoD jointly develop and implement
electronic health record systems or capabilities and accelerate the
exchange of health care information. The act also required that these
systems be compliant with applicable interoperability standards.
Further, the act established a joint Interagency Program Office to act
as a single point of accountability for the efforts, with the function
of implementing, by September 30, 2009, electronic health record
systems that allow for full interoperability.
This testimony discusses GAO's previously reported findings on the
establishment and evolution of the Interagency Program Office over the
last decade. In developing this testimony, GAO summarized findings from
its reports issued in 2008 through 2018, and information on the
departments' actions in response to GAO's recommendations.
What GAO Recommends
GAO recommends that VA clearly define the role and responsibilities
of the Interagency Program Office in the governance plans for
acquisition of the department's new electronic health record system.
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