[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
MISSION CRITICAL: CARING FOR OUR HEROES
=======================================================================
JOINT HEARING
before the
SUBCOMMITTEE ON HEALTH
and the
SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, MAY 22, 2019
__________
Serial No. 116-12
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
39-916 WASHINGTON : 2021
COMMITTEE ON VETERANS' AFFAIRS
MARK TAKANO, California, Chairman
JULIA BROWNLEY, California DAVID P. ROE, Tenessee, Ranking
KATHLEEN M. RICE, New York Member
CONOR LAMB, Pennsylvania, Vice- GUS M. BILIRAKIS, Florida
Chairman AUMUA AMATA COLEMAN RADEWAGEN,
MIKE LEVIN, California American Samoa
MAX ROSE, New York MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia JACK BERGMAN, Michigan
SUSIE LEE, Nevada JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR., DANIEL MEUSER, Pennsylvania
California STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN, W. GREGORY STEUBE, Florida
Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
Ray Kelley, Democratic Staff Director
Jon Towers, Republican Staff Director
SUBCOMMITTEE ON HEALTH
JULIA BROWNLEY, California, Chairwoman
CONOR LAMB, Pennsylvania NEAL P. DUNN, Florida, Ranking
MIKE LEVIN, California Member
ANTHONY BRINDISI, New York AUMUA AMATA COLEMAN RADEWAGEN,
MAX ROSE, New York American Samoa
GILBERT RAY CISNEROS, Jr. ANDY BARR, Kentucky
California DANIEL MEUSER, Pennsylvania
GREGORIO KILILI CAMACHO SABLAN, W. GREGORY STEUBE, Florida
Northern Mariana Islands
SUBCOMMITTEE ON TECHNOLOGY MODERNIZATION
SUSIE LEE, Nevada, Chairwoman
JULIA BROWNLEY, California JIM BANKS, Indiana, Ranking Member
CONOR LAMB, Pennsylvania STEVE WATKINS, Kansas
JOE CUNNINGHAM, South Carolina CHIP ROY, Texas
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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Wednesday, May 22, 2019
Page
Mission Critical: Caring For Our Heroes.......................... 1
OPENING STATEMENTS
Honorable Julia Brownley, Chairwoman, Subcommittee on Health..... 1
Honorable Susie Lee, Chairwoman, Subcommittee on Technology
Modernization.................................................. 3
Neal Dunn, Ranking Member, Subcommittee on Health................ 4
Jim Banks, Ranking Member, Subcommittee on Technology
Modernization.................................................. 5
WITNESSES
Dr. Steven Lieberman, M.D., Acting Principal, Deputy Under
Secretary for Health, Veterans Health Administration........... 6
Prepared Statement........................................... 35
Accompanied by:
Dr. Elyse Kaplan, PSY.D, Deputy Director, Caregiver Support
Program, Veterans Health Administration
Dr. Alan Constantian, Ph.D., Deputy Chief Information
Officer, Account Management, Office of Information and
Technology, Department of Veterans Affairs
Ms. Carol C. Harris, Director for Information Technology
Acquisition Management, Government Accountability Office....... 8
Prepared Statement........................................... 37
Dr. Wendell Ocasio, M.D., Chief Medical Officer, AbleVets........ 24
Prepared Statement........................................... 43
Mr. Ken Beecher, Director, Acumen Solutions...................... 26
Prepared Statement........................................... 44
MISSION CRITICAL: CARING FOR OUR HEROES
----------
Wednesday, May 22, 2019
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Subcommittees met, pursuant to notice, at 10:06 a.m.,
in Room 210, House Visitors Center, Hon. Julia Brownley
[Chairwoman of the Subcommittee on Health] presiding.
Present from Subcommittee on Health: Representatives
Brownley, Lamb, Levin, Brindisi, Rose, Cisneros, Dunn,
Radewagen, Barr, and Steube.
Present from Subcommittee on Technology Modernization:
Representatives Lee, Cunningham, Banks, and Roy.
Also Present: Representative Roe.
OPENING STATEMENT OF JULIA BROWNLEY, CHAIRWOMAN, SUBCOMMITTEE
ON HEALTH
Ms. Brownley. Good morning. Thank you all for joining us
today for a hearing to discuss the Information Technology
systems that support two of VA's most crucial programs, the
General Caregiver Support Program, and the Program of
Comprehensive Assistance for Family Caregivers.
While the VA provides essential health care services to
extremely disabled veterans, it is their caregivers that
provide the day-to-day services needed to sustain their well-
being. Caregivers are the most important component of
rehabilitation and maintenance for our veterans with severe
injuries and their welfare directly impacts the quality of care
veterans receive.
The VA Program of Comprehensive Assistance for Family
Caregivers is a one-of-a-kind in the United States. It is the
only integrated program that is required to provide health
care, a stipend, travel expenses, mental health care, respite
care, and injury-specific training. Without these supported
services, the quality of care provided by the caregiver is
likely to be compromised, and the veteran is more likely to
experience frequent medical complications and require expensive
long-term institutional care.
Veterans who qualify for the caregiver program are
medically stable enough to live outside an institution, but
lack the functionality to care for themselves independently.
When the program started in 2011, it was limited to
veterans who were severely injured on or after September 11th,
2001. It was estimated only that 4,000 veterans would apply:
however, over 45,000 applied, clearly demonstrating the
critical need for this program. Today, there are 20,000
participants.
Given the unique nature of the program and the larger-than-
anticipated demand, VA has encountered several complications,
including staff shortages, unclear procedures, and, the reason
for today's hearing, an antiquated IT system.
For the most part, veterans participating in the
Comprehensive Program have reported positively on their
experience. Their caregivers are better equipped to serve the
veterans and they experience fewer financial and emotional
stressors due to the availability of respite mental health care
and a monthly stipend.
However, in 2014 the GAO released a report highlighting the
degree of ineptitude of the IT system supporting the caregiver
program and recommended VA pursue a replacement system. VA
concurred with the recommendations and, 5 years later, nothing
has changed. It is deeply frustrating that 5 years after the
GAO report these IT problems persist. It is even more
frustrating that the only thing standing between pre-9/11
veterans and their caregivers and the services they need is
this IT program.
With the passage of the MISSION Act, Congress finally
rectified 8 years of inequality between pre and post-9/11
veterans, and made pre-9/11 veterans eligible for the program
upon the implementation and certification of a competent IT
system. The implementation deadline was October of 2018; VA
missed this date. Due on October 1 of this year is a report to
Congress that includes the system's full certification. I hope
very much that VA will assure this Subcommittee of their
readiness to meet that deadline and state when the first phase
of veterans, those injured before 1975, will be able to apply
for the program.
I had also hoped to hear from a representative of
Salesforce, the developer of the off-the-shelf system VA has
purchased to replace the current IT system, but to the
Committee's--to my disappointment and the Committee's
disappointment, they decided not to come.
What this Subcommittee hopes to learn today is twofold. The
first, why after 5 years has VA been unable to replace a faulty
IT system; and, second, what reassurances can you offer pre-9/
11 veterans and caregivers that continue to wait for access to
the care and services they need?
As our largest cohort, when Vietnam-era veterans age, the
demand for long-term care will grow significantly. Without the
caregiver program, these aging, severely injured veterans will
require the most intensive and expensive institutional care. I
would remind VA that the amount expended on disabled veterans
in these institutional settings can be anywhere from $56,000 to
$400,000 per veteran per year. The average cost to keep a
veteran at home in the caregiver program is only $19,000 per
veteran per year. By providing caregivers the means to keep
veterans at home with family, both the veteran and their
families will live healthier lives and delay higher costs. It
is simply a win-win: our veterans and their families are happy,
and the VA saves a significant amount of money that can be
invested into other critical veteran programs.
For decades, pre-9/11 caregivers have sacrificed their own
well-being in order to support the health and well-being of
their loved ones, who also sacrificed for us and for our
country. These caregivers have gained skills they never planned
to need. They are the reason their children were raised with
their veteran mother or father, the reason neighborhoods and
communities and families stayed whole. The caregivers and our
Nation's veterans, we need this program, and the caregivers and
our Nation's veterans, we need this program now. We made a
promise, now let's keep it.
Ms. Brownley. So I understand we have caregivers in the
audience today, and I want to thank each and every one of you
for all of your sacrifices and for being here today for this
important meeting.
I ask also for unanimous consent for other Committee
Members to join the dais for today's hearing. My understanding
is there are a few other members who may join us today.
And, with that, I will turn over to Ms. Lee for her opening
remarks. I recognize Chairwoman Lee for 5 minutes.
OPENING STATEMENT OF SUSIE LEE, CHAIRWOMAN, SUBCOMMITTEE ON
TECHNOLOGY MODERNIZATION
Ms. Lee. Thank you, Chairwoman Brownley. Thank you all for
being here and, most importantly, thank you to the caregivers
who are here as well.
Congress has given the Department of Veterans Affairs a big
mandate with the MISSION Act, because the responsibility that
we have to veterans and their families is so great. They have
sacrificed so much and in exchange we promise to provide them
with the best health care and services we possibly can. No
reasonable person can pretend that this is an easy task, but we
shouldn't make it harder than it needs to be. Yet time and
again we sit here and discuss failure, and we are assured that
lessons have been learned and that things would get fixed, and
here we are one more time.
At what point will the VA fix the systematic problems on
how it buys, implements, and manages IT? When is the VA going
to commit to getting it right and not make the same mistakes
with weak governance, inadequate program management, and poor
requirements development? Repeatedly making these same mistakes
is frustrating to everyone involved and also damaging to the
very people we intend to help. It is certainly incredibly
frustrating for this Committee.
It is clear that there were common themes on how the VA
fails at IT. At the top of the list is joint governance of IT
acquisition and implementation between the Office of
Information and Technology and the other VA program offices.
Who is leading? Who is accountable? I have the exact same
questions about every VA IT program, from Caregiver, to the GI
Bill, to the Electronic Health Record Modernization.
In the case of the caregiver program, we have one system
that was too small for the program; a failed effort to rescue
that system; and the complete scrapping of another system after
it was developed, accepted, and paid for by the VA due to
problems with user acceptance testing. Now, we embark on the
fourth effort to build an application with an uncertain
timeline and uncertain deliverables.
This new application, the Caregiver Record Management
Application, CARMA, is being developed on a Salesforce
platform. It was reported last week that this platform is the
subject of serious scrutiny in the technology community after
improper access was given to company employees, leading to a
forced widespread outage. It is unclear what the impact is to
the VA, but I hope the VA and the implementing contractor,
Acumen Solutions, is able to provide information about this
today.
Before the platform issue was known, we invited Salesforce
to testify today, but they declined to do so. This is
completely unacceptable. Oversight is not optional, especially
after $10 million in three failed tries. As the Committee
responsible for overseeing the implementation of VA programs,
we must have a meaningful opportunity to hear from everyone
involved, whether it is the VA, the IG, the GAO, veterans
themselves, VSOs, and certainly the contractors that stand to
profit from their work with the VA.
Furthermore, because these programs impact veterans, their
families, taxpayers, public oversight of these programs is
required.
I said at our recent hearing at the Forever GI Bill
implementation that I hoped the VA leadership would take that
IT failure as an opportunity to improve its other IT programs.
I want to understand if the VA is taking that heart or if it
has something substantive to offer today and how it is going to
get the caregiver program back on track. Our veterans are
waiting for this critical benefit, they should not have to wait
even longer because the VA can't get the IT right. Let's get
this right, and I hope we can have an open and productive
conversation on how we can do so.
I thank all of the witnesses for being here and I look
forward to your testimony.
Thank you. I yield back.
Ms. Brownley. Thank you, Chairwoman Lee. And I just want to
recognize the Ranking Memberof the Full Committee, Dr. Roe, is
here. Welcome. Thank you for joining us.
I would now like to recognize Ranking Member Dunn for his
opening remarks.
OPENING STATEMENT OF NEAL DUNN, RANKING MEMBER, SUBCOMMITTEE ON
HEALTH
Mr. Dunn. Thank you, Chairwoman Brownley. It is a pleasure
to be here today with you, and with Chairwoman Lee and with
Ranking Member Banks from the Subcommittee on Technology
Modernization.
We are here this morning to discuss continued programmatic
and IT challenges in the Veterans Affairs Caregiver Support
Program. The Caregiver Support Program encompasses a general
support program for veterans of all eras and a stipend-based
family caregiver program for post-9/11 veterans only. There is
no other benefit like this in the government or, that I am
aware, in the private sector either; it is truly unique.
Given that the VA is blazing trails with respect to this
program, it is unsurprising that there would be some growing
pains; however, it is disappointing that 8 years after the
program was implemented the VA is still experiencing serious
problems with the basic program functions, like consistency in
eligibility determinations and the lack of a functional
workflow management system.
Many of the issues that we will be discussing this morning
can be traced to a Government Accountability Office report that
was issued in September of 2014; that is 5 years ago. I will
leave it to my colleague and friend from Indiana, the Ranking
Member of the Subcommittee on Technology, Mr. Jim Banks, to
discuss the details of the IT system failures that bring us
here today, but suffice it to say it is unacceptable that 5
years have passed and the program still doesn't have the IT
system that it needs. That absence is even more concerning
given that Congress required the VA to expand the Family
Caregiver Program to family caregivers of veterans of all ages
and eras with the enactment of the MISSION Act.
Expansion is tied to a successful deployment of the IT
solution, so the longer it takes the Department to put a
workable IT system in place, the longer the pre-9/11 veterans
will have to be waiting to use it.
We saw the failed rollout of the Forever GI Bill last fall
and how student veterans suffered when the VA rushed to put a
system in place that wasn't ready for prime time; I don't want
us to make that mistake again. That said, I do want the VA to
recognize that tens of thousands of veterans and caregivers are
relying on them and awaiting for them with an approach of this
program, so I want a new sense of urgency in that.
And let me say, I am grateful to our witnesses and to my
colleagues from both Subcommittees for being here this morning.
And, Madam Chair, I yield back.
Ms. Brownley. Thank you, Dr. Dunn.
And I now recognize Ranking Member Banks for his opening
remarks.
OPENING STATEMENT OF JIM BANKS, RANKING MEMBER, SUBCOMMITTEE ON
TECHNOLOGY MODERNIZATION
Mr. Banks. Thank you, Madam Chair.
The Family Caregiver Program is an important lifeline for
about 20,000 post-9/11 veterans. As my colleagues have already
said, Congress believed the eligibility disparity among
different eras of veterans was unfair and the MISSION Act
eliminates it. But like so many other key programs, the Family
Caregiver Program relies on an IT system, and that system is on
the rocks. If it feels like we have been here before, it is
because we have.
In some ways, this is a similar situation to the Forever GI
Bill and the VBA Education Benefits Processing systems, but
what is different this time is that we recognize the risk in
advance. Expansion of the Family Caregiver Program is phased,
and it is contingent on the IT system being ready to handle it.
It would be unforgivable to push through the expansion with the
management capability and systems to handle it. As we have seen
before, that could result in undermining the program for
existing beneficiaries.
I am here to determine how close we are getting the IT
system over the finish line and whether I have confidence in
VA's decisions. In fact, it isn't one system, but a confusing
succession of four: the Caregiver Application Tracker, or CAT,
database that has been in use since 2011; the ill-fated CAT
rescue between 2015 and '18; the Caregiver Tool, or CareT,
developed beginning in 2015 and abandoned earlier this year;
and, finally, the Caregiver Record Management Application, or
CARMA, which is just beginning.
CAT is clearly inadequate and needs to be replaced, there
is no doubt about that, but I am not sure if that is because of
inherent design flaws or an operational failure to maintain it
and the integrity of its data.
Despite a series of staff-level meetings in preparation for
this hearing, we still don't know very much about CareT. VA
invested 3 years and several million dollars in CareT and
expressed confidence in it, until the assessment suddenly
became negative at the very end. My understanding is CareT
still exists in a nearly complete state on a VA test server,
but it is slated to disappear in the next few weeks.
Now there is CARMA, the latest and I hope final effort to
develop a more reliable and streamlined system, this time based
on the Salesforce platform. I have a lot of questions about
CARMA. VA has weighed the pros and cons, and decided the new
capabilities that will eventually be gained outweigh the costs
of going back to the drawing board. It is a big decision and I
want to make sure to understand what went into it.
I appreciate our witnesses today from VA, GAO, and the
companies being here. We need to hear from each of you to
understand why things happened in the past, what the
significant differences are among the various systems, and what
the critical path looks like to get CARMA in place to
accommodate the caregiver expansion.
With that, Madam Chair, I yield back.
Ms. Brownley. Thank you, Mr. Banks.
We have two panels for today's hearing. On the first panel
is Dr. Steven Lieberman, Acting Principal Deputy Under
Secretary for Health at the Veterans Health Administration. Dr.
Lieberman is accompanied by Dr. Elyse Kaplan, Deputy Director
of Caregiver Support Program, as well as Dr. Alan Constantian,
Deputy Chief Information Officer in the Office of Information
and Technology.
Also here today is Ms. Carol Harris, Director of
Information Technology Acquisition Management from the
Government Accountability Office.
I now recognize Dr. Lieberman for 5 minutes. Welcome.
STATEMENT OF STEVEN LIEBERMAN
Dr. Lieberman. Thank you. Good morning, Chairwoman Brownley
and Chairwoman Lee, Ranking Member Dunn and Ranking Member
Banks, and members of the Subcommittee. Thank you for the
opportunity to discuss--
Ms. Brownley. Is your mike on, Dr. Lieberman?
Dr. Lieberman. It is pushed in. You can't hear me?
Thank you for the opportunity to discuss VA's Caregivers
Support Program relative to the MISSION Act of 2018 and its
supporting information and technology systems. I am accompanied
today by Dr. Elyse Kaplan, Deputy Director, VA Caregiver
Support Program, and Dr. Alan Constantian, Deputy Chief
Information Officer for Account Management and Acting Deputy
Chief Information Officer, Account Manager for Health.
Since 2011, VA has provided groundbreaking work in this
country to deliver unprecedented benefits and services to
caregivers, so that the veterans they support may maintain
their highest level of health, quality of life, and
independence, and enable veterans to age in place by remaining
in their homes for as long as possible. They really do amazing
work.
The Program of Comprehensive Assistant for Family
Caregivers is currently limited to eligible veterans who
incurred or aggravated a serious injury in the line of duty on
or after September 11th, 2001, and their family caregivers.
Under the MISSION Act, the Program of Comprehensive Assistance
will expand to eligible veterans when VA certifies that it has
fully implemented the required IT systems.
Expansion will occur in two phases, beginning with eligible
veterans who incurred or aggravated a serious injury in the
line of duty on or before May 7, 1975, and 2 years later will
expand to eligible veterans injured during the remaining eras
of service.
Of note, the program of General Caregiver Support Service
already available to all veteran caregivers no matter what era
of service provides support such as assistance from a Caregiver
Support Coordinator, training, a Caregiver Support Line, and
peer support. Since its inception, VA has been optimizing the
Program of Comprehensive Assistance based upon feedback from
veteran caregivers, Veteran Service Organizations, and military
service organizations. We also have appreciated not only input
from them, but also from our Caregiver Survivor Federal
Advisory Committee.
A focus for VA has been to promote accurate and consistent
eligibility decision-making. Efforts under consideration are
redefining eligibility requirements and creation of
regionalized multi-disciplinary review teams to make
eligibility and appeals decisions. The latter will enable
consistency in determinations and remove medical center
clinicians from responsibility from such determinations, so
they instead can focus on supporting and caring for veterans
and caregivers.
Other improvements under consideration to the program are
providing financial planning and legal services, and modifying
the stipend payment to a more equitable methodology.
Additionally, governance of the program has been
strengthened by requiring every veteran's integrated service
network to have a lead to monitor administration of the
program, to ensure compliance with national policy and
procedures, and to provide support and oversight to Caregiver
Support Coordinators.
Another critical component of the success of the program is
to enhance staffing. VA is increasing staffing at its medical
centers and for its regional review teams.
VA recognizes our technology challenges. To better meet the
program's needs, OI&T and VHA executed a strategic pivot away
from a custom-developed system to adopt an industry-leading
commercial off-the-shelf platform suited for this need, which
can be configured to meet the specific requirements of the
Caregiver Support Program.
Additionally, VA has shifted from its prior approach of
seeking to deliver all desired functionality in one big release
to an approached grounded in agile development, best practices
for software development in widespread use across the private
and public sectors. We also designated a new role, a full-time
products manager, to ensure that we build a highly-function
product in an iterative manner, prioritize requirements to
assure caregiver program needs are met, and ensure future
expansion of the program.
The Caregiver Record Management Application, also known as
CARMA, will replace the existing Caregiver Application Tracker
with abilities such as managing applications, supporting
administration of the Program of Comprehensive Assistance,
tracking calls to the Caregiver Support Line, processing
stipend payments, and significantly improving reporting
capabilities.
VA recognizes the sacrifice and value of caregivers and
wholeheartedly supports expansion of the program of
Comprehensive Assistance to all eras of service. We remain
committed to meeting the needs of its stakeholders by
administering a program that is consistent in delivery,
transparent in process, and more easily understood by veterans
and caregivers. We have made significant progress and we will
continue to work hard to build upon the improvements made thus
far. We must get this right; our veterans and their caregivers
deserve nothing less.
We will not expand the program until we are certain that
our obligations for eligible veterans and caregivers are met.
Your continued support is essential to providing the care for
veterans and their families.
This concludes my testimony. My colleagues and I are
prepared to answer any questions.
[The prepared statement of Steven Lieberman appears in the
Appendix]
Ms. Brownley. Thank you, Dr. Lieberman.
Ms. Harris, you are now recognized for 5 minutes.
STATEMENT OF CAROL C. HARRIS
Ms. Harris. Thank you. Chairs Brownley and Lee, Ranking
Members Banks and Dunn, Dr. Roe, and members of the
Subcommittees, thank you for inviting us to testify today on
the IT challenges affecting VA's Family Caregiver Program. As
requested, I will briefly summarize our prior related work and
discuss critical factors underlying successful IT acquisitions.
As you know, the Veterans Health Administration established
the Family Caregiver Program at each of its VA Medical Centers
across the U.S. in May 2011. At that time, the Department
implemented an IT system called the Caregiver Application
Tracker, also known as CAT, to help support the program. CAT is
a Web-based system that was designed to facilitate the exchange
of information about approved caregivers between the VA Medical
Centers and other VHA entities. However, in 2014 we reported
that CAT, which is still in use today, had limitations.
For example, the Caregiver Support Program Office was not
able to easily retrieve data needed to assess workload trends
at the individual medical centers, such as the length of time
applications are delayed or the timeliness of home visits. As
such, program officials were limited in their ability to assess
the scope and extent of workload problems at the individual
medical centers and on a systemwide basis.
We noted in our report that VA had taken initial steps to
obtain another IT system to support the program, but it was not
sure how long it would take to implement. Accordingly, we
recommended that VA expedite the process for identifying and
implementing a system that would fully support the program. VA
concurred with our recommendation and subsequently began taking
action in 2015. These actions included steps towards
implementing short-term improvements to CAT that would be
followed by a long-term replacement system.
Unfortunately, VA's efforts to implement a fully capable
system have been ongoing for at least 4 years and there is no
end in sight. This morning, I will highlight two key points.
First, VA has undertaken two efforts, both of which have
failed, and recently started a third. In 2015, VHA and the
Office of Information Technology initiated a joint acquisition
project called CAT Rescue to update CAT and improve the
system's data reliability. This effort experienced delays and a
large number of defects during system testing. VA terminated
the project in April 2018.
A companion project to CAT Rescue was initiated in
September 2015 to develop the Caregivers Tool, a new system to
eventually replace CAT. However, system issues arose during
user acceptance testing that indicated the system was not
performing as expected. VA ultimately determined the system was
not a viable solution and terminated work in February of 2019.
VA and OIT began a third effort in March 2019 based on an
existing commercial product. This IT solution, referred to as
CARMA, is intended to replace CAT, and VA has not yet
established a date for completing it. We have ongoing work to
evaluate the Department's efforts and expect to issue our
report in early fall.
And now to my second point. There are a number of critical
factors VA could adopt to increase the likelihood that the
CARMA acquisition will be a success. Our work has shown that
successful IT acquisitions generally have nine critical factors
in common, and I will mention two here.
One is qualified and experienced program staff; this
included knowledge of acquisitions and procurement processes,
monitoring of contracts, and agile software development
concepts. The VA has historically developed its systems in-
house, and CAT, CAT Rescue, and CareT were no exception.
Acquiring a commercial product will require a different set of
skills that VA should ensure it can adequately bring to bear.
Another factor is testing early and often. The testing of
functionality by end users prior to acceptance demonstrates
earlier, rather than later, whether the functionality will meet
MISSION need.
The VA would benefit from applying the critical success
factors we identified. These factors can serve as a model of
best practices that could help VA deliver an IT system that
will effectively serve the Family Caregiver Program.
That concludes my statement and I look forward to
addressing your questions.
[The prepared statement of Carol C. Harris appears in the
Appendix]
Ms. Brownley. Thank you, Ms. Harris.
And now I would like to yield 5 minutes to Chairwoman Lee
for her questions.
Ms. Lee. Great. Thank you.
Dr. Lieberman and Dr. Kaplan, as I mentioned in my opening
statements, I am very concerned about VA's ability to govern IT
applications, and it is with all IT programs. So I want to ask
on this specific program some basic questions, just quick, you
know, setting the stage.
Who is accountable for this program?
Dr. Lieberman. I have overall responsibility for the
Caregiver Program, and for the actual IT system it is myself
and Mr. Jim Gfrerer.
Ms. Lee. Okay. VA told the Committee that it was going to
designate a Product Manager for CARMA; who is that?
Dr. Lieberman. Dr. Constantian, can you talk about it?
Dr. Constantian. Our Product Manager for CARMA is Ms. Ming
Ligh.
Ms. Lee. And what is her--is that her title or does she
have another title?
Dr. Constantian. I know her title with respect to the CARMA
project that she is the Product Manager. She is with VA's
Digital Services team.
Ms. Lee. Okay. What is the OIT's role and what is Caregiver
Support Program's role in ensuring the final successful
delivery of an IT service, Dr. Constantian?
Dr. Constantian. We build IT systems based on the
specifications and requirements of our business partners, and
testing goes in to make sure that those requirements have been
understood and articulated in the IT product.
With CARMA, we are sort of doubling down on the
intensification of the tastings, similar to what Ms. Harris was
saying about frequent testing. So, every 2 weeks we having a
sprint and for limited aspects of capability for a projected
release, and that sprint is where members of VHA's Caregiver
Program are working with our IT developer, Acumen, from whom
you will be hearing later, and determining whether those
requirements were well understood and whether that aspect of
the capability is delivering what the customer is looking to
receive.
Ms. Lee. Okay. So, every 2 weeks, you will have a sort of
check in. And at what point--you know, I am sort of looking at
what happened in the past and especially the scrapping of the
CareT program--at what point are we going to be notified of
possible issues?
Dr. Constantian. We have established targets for the first
two releases of discrete functionality of the CARMA product. So
this is another distinction in terms of how we are moving
forward with CARMA that we did not follow as rigorously in
previous efforts. And so this is this agile development process
where we are putting into production discrete components of
what the Caregivers Program needs.
So for the first release that is projected for October of
2019 we plan to fully replace the capabilities of the CAT
program. It also because of Salesforce's inherent--well, that
is the COTS product that we are using--because of its inherent
utility for case management, which this really is an
application of case management, the caregivers are serviced by
caseworkers and customer service calls and reports and typical
things are needed, we will have a full understanding probably
in the September time frame as to whether the entire capability
that is replacing the CAT system is in place, I would say by
September, but we expect the product to be done by October of
2019.
Ms. Lee. Okay. Can I request a check-in with this Committee
in September, just so we have an understanding of where that
stands? Thank you.
Dr. Constantian. Certainly.
Ms. Lee. Ms. Harris, quickly, do you see parallels right
now with this governance challenge in comparison with other VA
IT implementations?
Ms. Harris. The short answer is yes. I think having a
clearly defined governance structure is very critical. The
second component to that is having an adequate acquisition
program baseline that fully and clearly sets out the
commitments from a cost schedule and performance target basis,
and have that all clearly defined and, you know, transparent to
both GAO, as well as to you. That is a program baseline that we
have yet to see thus far.
Ms. Lee. Okay. Thank you.
I yield.
Ms. Brownley. Thank you, Chairwoman Lee.
I now recognize myself for 5 minutes.
I think the premise has been made clear that this is a
critically important program, that is why we have expanded it,
and we know that the demand for it is high. So, in the
President's budget request for fiscal year 2020, the VA
requested $720 million to support the Caregiver Program.
Included in that amount was $150 million for program expansion
efforts, but this is $100 million less than what the CBO
projected, and the Independent Budget recommended.
So how is this budget estimate arrived at, Dr. Lieberman?
Dr. Lieberman. So this projection was based upon input from
Milliman, who does our predicted model--
Ms. Brownley. Input from who?
Dr. Lieberman. Milliman. They always give us--we work with
them when we are determining future enrollment or numbers. And
there were many factors that went into their predictive model
and that included that as the veteran aged that they would more
likely be in need of caregiver services, that there would be
the 2-year gap, although that didn't go into the prediction for
that particular year.
Also, a big factor was that, based upon the first rollout
of the Caregiver, we didn't see 100 percent of the applicants
applying for the first year, it was more on the order of about
40 percent, and so that was put into the calculation also.
Ms. Brownley. So you have great confidence then that this
is an appropriate budget?
Dr. Lieberman. So--
Ms. Brownley. You are the final arbiter of that before it
goes to the White House, right, for them to create their
overall budget?
Dr. Lieberman. Absolutely. We are--now that Dr. Kaplan and
I are involved, we are actually taking another look at it--we
were not involved in this previously--to make sure we agree
with it. We also are working with Milliman to look at the
latest numbers and see if it impacts at all on our prediction.
Ms. Brownley. So, you know, in addition to $100 million
less, according to the budget submission, the Caregiver Program
has yet to determine either the program's overall staffing
model, or the definitions and criteria for severe injury. So I
am just wondering how this third party came up with a budget
without staffing levels and without this really critically
important definition for serious injury.
Dr. Lieberman. So we are certainly looking at the budget as
we update our staffing models. We believe that the budget will
meet our needs, but we are taking a serious look at staffing in
both the facilities and for these regional evaluation teams.
And we also believe that the final definition of a serious
injury, whatever it comes out to be, that we will have adequate
funding for that in the short term.
Dr. Kaplan, anything you want to add?
Dr. Kaplan. Thank you. I would just add that we have been
working with Workforce Management to predict those staffing
models as well and have good confidence that we are going to be
able to provide those services. One of the things that we are
doing to shift the focus in some ways from just having the
Caregiver Support Coordinator at each medical center is having
these regional eligibility teams, and so that will take a lot
of--
Ms. Brownley. Thank you.
Dr. Kaplan. Sure.
Ms. Brownley. Thank you. And I just want to make sure
that--do we know when the program is going to start? So you
have created a budget, you have created some money for
expansion, when is the program going to start? The expanded
program let me say.
Dr. Lieberman. We do not have a definite date yet. We are
waiting for the determination on when the IT system will be
fully operational.
Ms. Brownley. Okay. Ms. Harris, do you think that this is
the right foundation for building a budget?
Ms. Harris. Well, because the IT solution scope is not yet
fully defined, as well as the cost and schedules, at least not
to our knowledge since we haven't seen a program baseline, I
don't think that the confidence in the current budget can be
very high. Because, again, if the IT solution is what is
necessary to expand the program, it doesn't have an adequate
definition or adequate commitments locked in place, then it is
not a good basis for moving forward.
Ms. Brownley. Thank you for that.
My time is up, and I now recognize Ranking Member Banks for
5 minutes.
Mr. Banks. Thank you, Madam Chair.
Ms. Harris, welcome back to the Subcommittee. We always
value your expertise.
In your testimony, you outlined nine critical success
factors for IT projects; which of the factors do you see
present in these Caregiver system development efforts and which
ones are lacking?
Ms. Harris. The ones that we see in terms of lacking is
having program staff with adequate knowledge and skills. You
know, the VA does not have the core competency in acquiring
commercial products, they have historically developed their
systems in house, and so that is a completely different animal
from acquiring commercial product and utilizing agile
development processes to do so in the configuration, as well as
the customization, of the ultimate solution.
And so ensuring that VA has the adequate program management
knowledge to carry out an agile development project is going to
be very critical for their success.
Another key weakness is testing early and frequently. That
is something that--in their previous failed efforts was
something that they were lacking in. And so I am pleased that,
you know, they will be going towards more modernized software
development approaches in this testing early and often, but the
linchpin here is really going to be whether they have the
adequate experience and knowledge to be able to adequately
acquire it.
Another critical success factor is also in ensuring that
stakeholders are actively participating on this program and
that is--you know, stakeholder involvement, not just--and
through the procurement process, all the way through the
development and prioritization of the requirements, and then
all the way through the final delivery, that is going to be
essential.
Mr. Banks. Dr. Constantian, I understand you plan to
release the new CARMA system in three phases, Phase 1 in
October, Phase 2 in January 2020, and then Phase 3 at a date
that has not yet been determined. I have several questions for
you about that.
VA is calling CARMA Phase 1 the minimally viable product.
Is it also fair to call the Caregiver Application Tracker, CAT,
system a minimally viable product since you are using it now to
administer the program despite being dissatisfied with it?
Dr. Constantian. The CAT system I would not characterize as
a minimum viable product. The minimum viable product as a term
is used as you are building incrementally a system and adding
additional functionality. Characterizing a system that is
already existing and function which we do not have any plans to
expand upon would not be an appropriate use of the term, sir.
Mr. Banks. In Phase 2 of CARMA you are going to release a
stipend-processing capability. Does CAT do stipend processing
now? And how about CareT?
Dr. Constantian. CAT--obviously, we have to pay our
caregivers, so caregivers are paid, but that is done outside of
the CAT system through a manual procedure. That is for CAT.
CareT had within the scope of the requirements that it was
seeking to deliver, did have a stipend determination and
payment complement to it, yes, sir.
Mr. Banks. Okay. In Phase 3, I understand that you are
going to add capability to put the caregiver application form
online and make all of the enhancements necessary for the
Caregiver Program to expand per the MISSION Act. That sounds
like all the functions we don't have now in CAT; would you
agree with that characterization?
Dr. Constantian. Well, yes. And Phase 3 could be in several
sub-phases. We release product, consistent with agile
development, we release at least every 90 days into production
and put it into the hands of the Caregiver Program
capabilities. So--
Mr. Banks. So, in other words, CARMA doesn't gain functions
that are fundamentally different from CAT until Phase 3?
Dr. Constantian. No, no. No, you are correct. So, for
example, Phase 2 has the stipend calculation capability that is
not inherent in the CAT system, so that will be in place in
Phase 2. And then the--among other things, the front end where
a caregiver can make an online application, that is in--
Mr. Banks. Okay. So, really quickly, we don't know yet when
Phase 3 will begin. The staff did a demo on CAT and it is
definitely a primitive-looking system. But that said, how do
you justify spending probably another year on CARMA before we
get anything new out of it?
Dr. Constantian. It is precisely as the Committee
described. This is such an important program, and a
groundbreaking and pioneering program, that we want to make
sure that the system support is absolutely capable of
supporting the program without any hiccups and burps after we
have launched the expansion. So it is our commitment to make
sure that with CARMA our VHA business partners have 100 percent
confidence in the system to do their expansion.
Mr. Banks. Okay. My time has expired.
Ms. Brownley. Thank you, Mr. Banks.
And I now recognize Ranking Member Dunn for 5 minutes.
Mr. Dunn. Thank you, Chairwoman Brownley.
Let me start with Dr. Kaplan. What percentage of those
veterans currently in the program would require a nursing home
if it were not for them being on the Caregiver Program?
Dr. Kaplan. So that is a really interesting question and I
think we will have to take that for the record. It is very
difficult to tease apart exactly what the needs are of that
caregiver and of that veteran, and so pulling the veteran out
separately to--our capabilities just aren't showing that right
now. So I will take that for the record.
Mr. Dunn. When we are calculating how much money we are
saving with the program, I mean, that is a fundamental number
we would like to have I think a grasp on.
Do you have an estimate for how many veterans might enter
the program with the new expansion?
Dr. Kaplan. We do have estimates. They range considerably
and so we are working with Milliman, our actuaries, to really
better define those projections. We know that as--
Mr. Dunn. Do you have an estimate?
Dr. Kaplan. So the estimate could be anywhere from 60,000
to 100,000.
Mr. Dunn. Sixty to--
Dr. Kaplan. Sixty to a hundred thousand.
Mr. Dunn. Sixty to a hundred thousand. Thank you.
Ms. Harris, I am not a programmer, I admire you for being
one. I am familiar with the Salesforce software; I have used it
in a couple different corporations. It seemed pretty
comprehensive, although I think it lacked a payroll system; am
I correct?
Ms. Harris. Sir, we currently have ongoing work to evaluate
CARMA and the Salesforce solution, but at this time I am not
very familiar with the current product suite of Salesforce.
Mr. Dunn. So it is really basically a fairly complex
spreadsheet. And when we talk about all these programmers you
need, it seems to me you might, may be aiming in the wrong
direction, which you want people competent with spreadsheet
development. That was my experience with it. Believe me, if I
could use it well, I think you have got a lot of people back
home who could probably do that as well.
Let me turn back to Dr. Kaplan again. I fear we focus so
much attention, honestly, on the Family Caregiver Program that
some of the services and supports that VA offers under the
general Caregiver Program go unnoticed. Can you talk a little
bit about what the services are that a veteran and their
caregiver who are not eligible for the Family Caregiver Program
might receive under the general program?
Dr. Kaplan. Certainly. So that is something that we spend a
lot of time talking about. We really want to ensure that the
focus is on our general caregiver services. We provide
education, training, respite, social support, and peer support
mentoring to all of our general caregivers. We also provide
them with self-care courses, maybe even courses and training
specific to what their veteran may have, whether it is
Alzheimer's disease or multiple sclerosis or PTSD.
So making sure that we have an enhanced system to provide
those general caregiver services is paramount to us expanding
and to being able to provide services for all veterans and
their caregivers.
Mr. Dunn. And I trust we are doing outreach, so the
veterans know that these services are available?
Dr. Kaplan. Certainly. There is a Caregiver Support
Coordinator located at every medical center and we are going to
focus on actually having someone at each medical center to
focus on general caregiver support services.
Mr. Dunn. Excellent. Thank you.
Chairwoman, one more question for Ms. Harris, if I may. You
know, in the long run after the end of this--we get CARMA
instituted, it is going to have to integrate with the VA EMR
system, I think. Are you optimistic? Just give me some--
Ms. Harris. I mean, system integration and the number of
system interfaces is not yet clear to us right now. I am not
quite sure whether VA has adequately defined that as far as the
number of systems and the--
Mr. Dunn. So that is the hot problem we have all had with
our EMRs, integrating them with anything, including another
EMR.
Ms. Harris. And it is certainly a challenge that VA will
face. It is a difficult challenge across the government to
integrate the system with--
Mr. Dunn. Let me thank all the witnesses. I want to say,
Dr. Lieberman, we haven't had a chance to interact as much as
we should have, and I would like to remedy that situation going
forward. You know, obviously, the Committee and you should be
having a regular dialogue and I apologize that we have not done
that before. Let's make sure we do that in a somewhat less
stilted fashion.
With that, I yield back. Thank you.
Ms. Brownley. Thank you, Dr. Dunn.
And I now call on Mr. Lamb for 5 minutes.
Mr. Lamb. Thank you, Madam Chairwoman.
Ms. Harris, you highlighted the difference between the VA
buying an off-the-shelf solution with this new product versus
what they were doing before, could you explain in just a little
more detail the difference between those two things from the
VA's perspective? Like were they themselves really developing
the software solution before or how are those different?
Ms. Harris. My understanding is that for CAT, CAT Rescue,
and CareT, VA was developing those solutions in house; those
were not based on commercial platforms or commercial products.
The CARMA solution is based on a commercial product. So the
difference being, because the previous solutions were developed
in house, they had coders and engineers, folks responsible for
developing that software, now in this different paradigm, you
know, this acquiring a COTS product, they are going to have
to--they won't be the developers anymore, they will be
overseeing contractors who will be responsible for the
configuration and the customization of that product.
And so they will be responsible for contractor insight and
ensuring that they have the right end users that have a
frequent dialogue with those software developers to ensure that
when these short sprints or product releases are released into
the environment that it has been adequately tested and all the
kinks have been resolved. And so it is a different animal from
actually being the developers themselves.
Mr. Lamb. That sounds to me very similar to the way that
VistA was developed in house within the VA for medical
records--
Ms. Harris. Correct.
Mr. Lamb [continued].-and now we are moving to Cerner; is
that a fair analogy for the two situations?
Ms. Harris. Yes, sir.
Mr. Lamb. Okay. Dr. Constantian, I see you nodding your
head. How long have you been at OIT?
Dr. Constantian. I have been in OIT for about 7 years.
Mr. Lamb. Okay. Why are we making this move in both cases,
in your opinion? Do we not have the in-house talent in the VA
to work on these programs themselves, or what is with the shift
in thinking here?
Dr. Constantian. Congressman, we back in 2016, under the
leadership of LaVerne Council, moved toward a philosophy of
moving to COTS and strategic sourcing, which our current CIO,
Mr. Jim Gfrerer, heartily endorses.
Part of the reason for that, it is not necessarily internal
capability, it is the ability to share development costs with
the private sector who are building products that are adaptable
in the VA environment. So we are following the same approach
with CARMA by adopting Salesforce that we did by adopting
Cerner for the electronic health record, and that is
benefitting from industry-wide best practices in a particular
area and then making configuration changes of that COTS
platform to suit specific VA needs. So it is a move toward COTS
as a philosophy of, you know, buying COTS first where COTS is
suitable for the solution.
Mr. Lamb. Okay. Now, in both cases, obviously one of the
big concerns is how we are going to hold the contractor to some
sort of time line and result-oriented standard, but it sounds
to me like as we sit here right now we really don't have any
idea when this new product is going to be ready to go; is that
a fair statement?
Dr. Constantian. So, with agile development, you capture
different user stories and epics, and basically bundles of
functionality that you want to deliver. So we have pretty well
fixed the first two bundles of functionality, the first one
replaces completely--
Mr. Lamb. I hate to cut you off, but we are running out of
time. As we sit here today, the people that you have contracted
with for this new system, do they have a concrete deadline as
to when it has to be ready, at least for its first phase?
Dr. Constantian. For the first phase, our planned target,
and we have good confidence in it, is that we will have that in
October of 2019.
Mr. Lamb. Is that a contractual deadline that they are
bound to?
Dr. Constantian. I do not believe so.
Mr. Lamb. Okay. So I just want to be clear, because
obviously there are real families behind this situation and
these are older families, because we are expanding this program
to people from pre-9/11, so Vietnam era, many of them, they and
the people that they are caring for don't have very much time
left in a lot of these cases.
So if I am asked by one of them at home, which I often am,
I heard we were getting these benefits, where are they, I am in
a position right now to say that we have contracted with
someone to fix this, but they are not held as of right now to
any actual deadlines; is that right?
Dr. Constantian. We are expecting them to deliver the first
phase in October. I will have to get back with you for
something on the record as to whether there is a contractual
basis for holding them accountable to particular phases of the
development.
Mr. Lamb. Thank you. I am out of time.
Thank you, Madam Chairwoman.
Ms. Brownley. Thank you, Mr. Lamb.
And I now call on Dr. Roe for 5 minutes.
Mr. Roe. Well, thank you. I won't be long, Madam
Chairwoman, I don't think. And certainly I have difficulty
turning an iPad on, so I know the complexity of this has to
be--you have got a lot of smart people trying to make it work,
but to Mr. Lamb's point, the veterans out there really don't
care. What they want to know and what I would like to know is,
when are we going to sign the first one up? When can the first
pre-9/11, my generation--and I noticed Mr. Lamb looked around
when he said, you know, some of us weren't going to be around
long, he was looking at me when he said that--
[Laughter.]
Mr. Roe [continued].-but, seriously, when can we go home to
our constituents, because we get asked this all the time--they
know it has passed, many people know, and we had a lot of
stakeholders put a lot of effort, the Dole Foundation and
others, into getting this done, and he is correct, this is
affecting a generation that are dying at hundreds per day.
Dr. Lieberman. We want to get this done as quickly as we
can also. This is such a critical program, as you state. We do
not have that date; we are unable to commit to that date yet.
Mr. Roe. Okay. So we don't know when that will be.
The other thing, and Ms. Brownley was on to this, and when
you were estimating--and I will give the VA an A-plus--when
three ADLs were used, you all estimated almost to--I mean, it
was amazing how close you got to around 5,000 veterans that
would be using this caregiver program, but when it was
liberalized to one ADL, that is when the number went up to
around 20,000. I just did some tabletop math here, pretty
simple math, we are spending $20,000 per person, and 60,000 is
a $1.2 billion program, not $150 million. It is almost ten
times what we have--and if it is north of that, 100,000 people,
we are looking at $2 billion.
So the estimate, as best I can tell, is way off. Unless we
don't implement the program where you don't spend any money
except on technology, it is not working.
So am I wrong there?
Dr. Kaplan. So I can appreciate that. And so part of that
is that we are planning for a 40 percent ramp-up for the first
year. So 40, 70, and then 90 percent for the following year.
The other pieces of that being that, you know, we are
reevaluating those numbers, because I think we want to make
sure that the considerations for those numbers and projections
are just and are sound. And when we do have--one of the other
reasons I think that there is so much flexibility and
disagreement in the numbers is simply because we have not
standardized our decision-making in terms of eligibility to the
extent that we need to, and that is part of our regional
eligibility teams. So being able to standardize our decisions
that much more.
Mr. Roe. I certainly know when Dr. Shulkin was testifying,
I remember the hearing we had last year when he was talking
about--even before we passed the MISSION Act, he was talking
about using three ADLs, which I supported; I think that is what
the industry standard is, but right now it is one. And I just
quickly did--I wasn't very good in calculus, but I was pretty
good in arithmetic, and if you look at 40 percent of the low
number, that is still almost a half a billion dollars. So we
are--I think Ms. Brownley is on to something, we have grossly
underestimated what this is going to cost.
And I think back to the frustration that this Committee
has, we look at the--and one of the concerns, I mean an
absolute red flag in front of the bull that I saw out in
Spokane a year and a half ago when I was out there was how the
IT program with Cerner was rolling out. And then we see the
Post-9/11 GI Bill roll out, that is supposed to be by December
of 2019 up and functioning, and I am not convinced it will be.
And we specifically put in law that we would not go live with
this program until you all, the experts, can certify the IT
program. So that holdup of the IT is keeping a lot of World War
II vets, Korean War vets--think about that when you go home
tonight, the elderly people that desperately do need this,
think about that.
And I yield back.
Ms. Brownley. Thank you, Dr. Roe. And I now recognize Mr.
Levin for 5 minutes.
Mr. Levin. Thank you, Chair Brownley. As Dr. Roe said, we
all have huge numbers of veterans in our communities, in my
district, in San Diego, and I am very troubled when I hear
about these IT issues. I chair the Economic Opportunities
Subcommittee and we just had another joint hearing with the
Technology Modernization Subcommittee where we learned about
other IT implementation problems with regard to the GI Bill and
benefits there.
And I am trying to understand how we can prevent this from
happening in the future, what proactive steps you are taking.
And, you know, here we are examining more than 8 years of
fruitless efforts to develop a caregiver eligibility tool and
management system. Several questions for a couple of you.
Dr. Constantian, what lessons would you say OIT has learned
in the last 8 years that are reflected in your current approach
with Salesforce and Acumen?
Dr. Constantian. I think one of the lessons that we have
learned is to not assume that we fully understand the
requirements without having extensive dialogue between our
developers and our IT staff with our business partners. It is
one thing to write down requirements, just like in any kind of
communication. It is one thing for somebody to try to convey a
meaning. It is another thing for another party to understand
that same meaning and be on the same page. So I think that is
something that we have learned.
The second thing I think we have learned is that in terms
of process, saying that we are doing--following an agile format
and actually doing it, as we are doing with CARMA now with two
week sprints. Checking in regularly with the customer on
smaller elements of functionality, I think, is a lesson learned
and something that we're doing better now than we did in the
prior attempts.
Third, I think that the practice of committing on the part
of both the business partner and the IT organization, to put
some level of capability into production and using it, which we
are doing with the Phase 1 of CARMA in October, where we will
discard CAT and we will build from this new Salesforce
platform, KARMA, and then incrementally build and add
additional functionality is something that we did not do with
CareT that we are doing.
And then a third item is having a product manager, which we
have not had. We have had more of a hands off project
management, letting the contractors work more directly with the
business. We are very involved now. The development team is
very involved in the process. Ms. Lee is intimately involved
with what is going on. So that is a practice that has improved.
And I think in terms of technology, when we kicked off
CareT in 2015, because there were two contractors involved with
CareT, we had to stop the development of one contractor of
CareT which was ManTech, because what we were expecting to be
delivered under CAT rescue, which was a dependency, didn't come
across in time. What we have learned is that technology
improves and Salesforce, now, we had a--in 2019, we had a BPA
available for Salesforce that we could move to. And so to take
advantage of strategic sourcing opportunities, I think, are
other things that we have learned.
Mr. Levin. So I wanted to dig into CareT with the time I
have left, and I also was not great at calculus, but pretty
good at arithmetic. Three years, $7 million were spent for
Caret's development. Contract awarded to ManTech, as you said,
September 2015. And then in July 2017, an additional $4.3
million contract was awarded to AbleVets to fix various
defects.
And in their written statement, AbleVets indicated they
delivered a working product earlier this year. However, they
were then informed that the department was completely scrapping
the CareT system. So Dr. Lieberman, do you agree with AbleVets'
evaluation of their results and what was the VA's reasoning for
tossing the CareT system after investing $7.3 million?
Dr. Lieberman. First and foremost for us was expansion of
the program. And we wanted to have confidence in the product
that we were using. We were seeing--from the business side, we
were seeing too many defects and we did not have confidence
week after week. We were being told that we were going to have
the finished product, but we were not convinced, and we felt
like we had to know that we had a product that we could build
upon that was going to be successful. And so we looked towards
our colleagues in information technology, and their
recommendation was that we go with an off-the-shelf product.
And after reviewing, we agreed that we wanted to be certain
moving forward we were going to have the right product.
Mr. Levin. Well, I am out of time. Obviously, we want to
try to avoid wasting millions and millions of our veterans'
dollars in the future and I look forward to hearing from you
and seeing what kind of changes you will make to avoid this
from happening again. Thank you.
Ms. Brownley. Thank you, Mr. Levin. Ms. Radewagen, you are
recognized for 5 minutes.
Ms. Radewagen. Thank you, Madam Chairman, and I welcome the
panel. My question is for Dr. Constantian. How do you rank the
caregiver IT systems in terms of complexity and difficulty,
compared to the other IT systems the Committee has examined
recently, like the decision support tool for community care and
the long-term solution for the forever GI Bill?
Dr. Constantian. Congresswoman, I--it would be a subjective
guess and I don't really have a good basis for comparing the
complexity of the three systems.
Ms. Radewagen. Okay. So here is another one. So VA has
repeatedly stated the current system, CAT, is not able to scale
up to handle the increased numbers of veterans and caregivers
under the caregiver program expansion. Can you explain why that
is?
Dr. Constantian. Well, CAT was only developed to
accommodate 5,000 records. It's accommodating now I think about
20,000 active caregivers and has more records in the archive.
We do not believe the current technology is capable of
expanding beyond that, which is part of the reason why, based
on our own assessment and GAO's recommendations, we moved to a
solution CareT, and now CARMA that is scalable to whatever the
expansion is that we finally wind up with the MISSION Act
expanded program.
Ms. Radewagen. Thank you, Madam Chairman. Yield back.
Ms. Brownley. Thank you, Ms. Radewagen. Now, I am calling
on Mr. Cisneros for 5 minutes.
Mr. Cisneros. Thank you, Madam Chairwoman. Ms. Harris, in
your testimony, you identified nine critical success factors
that are consistent with leading industry practices for IT
acquisition, and you highlighted two of them, program staff and
active engagement of program officials with the stakeholders.
Is the VA following these nine critical success factors?
Ms. Harris. I can't tell you that at this time. We have
ongoing work to evaluate the current efforts with this third
effort. And so we intend to report back to you with the final
report in early fall.
Mr. Cisneros. Have they followed them in the past?
Ms. Harris. No, they have not.
Mr. Cisneros. Dr. Constantian, I am sorry if I said it
wrong, are we testing the CARMA program?
Mr. Constantian. Yes, frequently. As I had mentioned, at
the end of each of the two week epochs, Acumen is working with
the testers, with VHA and the caregiver program to make sure
that that discreet bundle of functionality we have gotten
right.
Mr. Cisneros. And how are the tests going? Are they being
successful?
Dr. Constantian. My understanding is so far things are
looking good.
Mr. Cisneros. Sir, are you getting reports every two weeks
as far as that testing and how it is going, or are you just
assuming right now that it is, like you said, under your
understanding, it is going well?
Dr. Constantian. We are getting weekly reports from the
product manager.
Mr. Cisneros. All right. So my question is we have had
problems with implementation before, what has changed this time
around to make us think that we can get CARMA implemented and
have it by October of 2019, as you are saying it will be done?
What has changed?
Dr. Constantian. Well, it is the--the first phase of CARMA
will be done by October of 2019. So I think three things have
changed. I think--and I would characterize them as people,
process, and technology. Those are the three elements of the
change.
In terms of people, we have, as I had mentioned earlier, a
product manager who is very intimately involved with the
development and the testing of the product on a weekly basis,
and this is the person from whom we get weekly reports.
In terms of process, we are more intentionally using an
agile development program where we are--and part of it is that
2 weeks testing of each incremental sprint, but also it is
putting into production for general use phases of
functionality. Phase 1 is replacing CAT, which provides
reports, registers people who are in the caregiver program,
takes information on what is coming from the caregiver support
line and from the caregiver support managers.
Phase 2, targeted for January of 2020, doing the automated
stipend processing. So those are the process elements using
this more agile development--deliberate agile development
process.
And then finally in terms of technology, using Salesforce
as an out of the box capability, a cots capability that is
applicable to this kind of IT solution has to be customized,
because as the Committee has very correctly noted, this is a
pioneering program. There is no other similar benefit in
government or the private sector. You are absolutely right with
that. So there has to be some customization. But Salesforce
brings out of the box capabilities in terms of reporting that
we did not have in a custom developed system that we have had
in the past.
So that for people, process, technology, those are things
that give me confidence that we will be successful with CARMA.
Mr. Cisneros. So we are testing the other phase outs too?
So Phase 2 is being tested, as well as the current Phase 1. And
then after Phase 1 is done, we will make sure that, or are we
waiting for Phase 1 to be completed before we start testing
Phase 2?
Dr. Constantian. Some work is being done on Phase 2 in
terms of understanding the requirements, but sort of the--as
you are writing code, any changes in the code can impact on the
tests from the previous code. So you have to do regression
testing. And so you really can't declare something. You can't
in parallel complete testing for future phases until you have
completed it sort of serially in Phase 1 and Phase 2. So there
is work being done with Phase 2 right now in terms of
understanding the requirements, but the testing focus is on
Phase 1.
Mr. Cisneros. Well, I have my fingers crossed that this is
going to work, Phase 1, because a lot of people are depending
on this and I hope it does. With that, I will yield back my
time.
Dr. Constantian. I hope so too, sir.
Ms. Brownley. Thank you, Mr. Cisneros. Mr. Barr, you are
recognized for 5 minutes.
Mr. Barr. Thank you, Chair Brownley. And thank you for
holding this hearing to shine a light on the serious problems
that we have experienced in the rollout of the IT systems
associated with the Family Caregiving Program.
And as I sit here and I listen to the testimony here today,
I can't help thinking about the veterans I have a privilege to
represent and what they would think if they were sitting here
listening to this today. And unfortunately, and excuse me if
this sounds harsh, I know these men and women. And I think if
they were sitting here today listening to this, they would say,
``Wow. This is a program that is replete with waste,
mismanagement, and poor performance.'' And that is harsh and I
am sorry to have to say that, but I know the veterans I
represent and I think they would be very disappointed to hear
that after 8 years and three failed efforts, and scrapping of
CAT Rescue, and CareT after an initial round with CAT, and now
moving into CARMA with no end in sight, and millions of dollars
of taxpayer investment now totally a sunk cost, I think our
veterans would be extremely disappointed.
And by the way, not just those pre-9/11 veterans who are
now supposed to be eligible but can't access the services that
Congress intended to provide for them, but I also worry about
the post-9/11 veterans and their caregivers, who I am not sure
they are getting the services that they have earned either.
And so let me first ask that question. And let me stipulate
up-front. You all are the experts. By far, I am not an IT
expert, so I will defer to your expertise, but I want to know
for the post-9/11 veterans and their caregivers, how has this
repeated failed effort to implement the IT systems, how has
that lack of capability impacted the post-9/11 veterans and
their caregivers? And I will start with Dr. Lieberman on that
point.
Dr. Lieberman. It has really not had an impact. The program
has been successful. Certainly, it would be more helpful for us
to have better data reporting analysis of how the program is
going, but we are still enrolling veterans. We are still
getting applications and we are still enrolling veterans. And
we are, based upon having caregivers support coordinators at
each facility, putting a lead in our networks, we are keeping a
close eye on how the program is going and we are making sure
that our caregivers are getting the services that they need to
serve their veterans.
Mr. Barr. Well, I certainly hope that is true, especially
with the initial round of veterans who are supposed to be
getting these services. But, Dr. Lieberman, as a follow up,
let's talk about the MISSION Act and the rest of the veterans--
the pre-9/11 veterans who are supposed to be receiving these
services. And I want to be absolutely sure I understand this.
Is it accurate that it is necessary to complete Phase 3 of
CARMA--of the CARMA system before the Family Caregiver Program
can expand?
Dr. Lieberman. That is correct.
Mr. Barr. Okay. So that is the group that is really being
negatively impacted by all of these delays and these failed
efforts; is that a fair characterization?
Dr. Lieberman. Yes, the pre-9/11.
Mr. Barr. Okay. Let me ask you this. So CARMA is going to
be an off-the-shelf application; is that right?
Dr. Lieberman. Yes.
Mr. Barr. Okay. Why didn't we, and the VA in general has
moved to an off-the-shelf--commercial off-the-shelf IT
mentality, Dr. Constantian. Why didn't we have that approach to
begin with? Why didn't we use that approach to begin with?
Dr. Constantian. Congressman, in retrospect, maybe we
should have, but in 2015--so where we were in 2011 was a
product was very quickly built to conform with the 2010
legislation that provides some kind of IT support in 2011. That
was CAT. So in 2015, with CAT Rescue, which was a short term
fix of some of the shortcomings of CAT and then CareT, we went
down what in 2015 was our sort of normal operating procedure,
which was to do custom development.
In 2017, after we did not have the database that the
original contractor, ManTech, for CareT needed to continue, we
awarded a contract to AbleVets, but based on taking over the
ManTech Solutions. So the 2015 decision on how to do the
solution sort of stayed with us until early 2019 when we moved
to Salesforce.
Mr. Barr. My time has expired, but I do worry that Ms.
Harris and the GAO is telling us that the VA lacks the
competency and experience to acquire these commercial products.
So I do hope the commercial off-the-shelf, the move to that is
better than the previous efforts. I yield back.
Ms. Brownley. Thank you, Mr. Barr. And just before I excuse
the panel, I just want to make one final remark and when we
passed the MISSION Act, it was very clear with this Committee
that our intention and motivation was to expand this program to
every single veteran in our country and their families who is
deserving of it and meets the qualifications. And I will say
what I said in my opening comments, I will conclude here, is
that if there is any effort on the VA's part to try to reduce
this program to squeeze it into a budget that I believe is
underfunded, this Committee is going to be very, very angry. I
just want to be abundantly clear.
And we have to look at this holistically because the
caregiver program is a win/win situation. It is what our
veterans want. It is what their families want, and it is
cheaper for us to do. So it makes no sense not to be in a
situation where we want to do everything possible to expand
upon this program, particularly as we will be facing our aging
Vietnam veteran population. It is only win/win for everyone.
So I know you all have a lot of work to do to make this
right. I appreciate you being here and participating today. And
I would now like to move onto our next panel. Thank you very
much.
Well, we will begin. Well, welcome, our second panel. And
on our panel this morning, we have Dr. Wendell Ocasio, chief
medical officer of AbleVets, and Mr. Ken Beecher, director of
Acumen Solutions. Dr. Ocasio, you are now recognized for 5
minutes.
STATEMENT OF DR. WENDELL OCASIO
Dr. Ocasio. Chairwoman Brownley, Chair Lee, Ranking Member
Dunn, Ranking Member Banks, and distinguished members of the
Subcommittees, thank you for this opportunity to testify today.
My name is Wendell Ocasio. I am a chief medical officer of
AbleVets, a certified Service-Disabled Veteran Owned Small
Business specializing in cybersecurity, agile engineering,
analytics, and technology enablement solutions for government.
In summary, AbleVets was awarded the CareT contract on July
5th of 2017. The original requirement for the 10-month base
period was for AbleVets to start with an existing CareT
application code base, implemented a defined set of additional
application requirements, migrate data from the CAT Rescue into
the CareT product, test the final product, and deploy into
production. And there were two 12-month optional periods
focused solely on sustaining the CareT application code once
deployed into production.
AbleVets was obligated 3.5 million over a 23-month period,
successfully completing and delivering the base period
requirements. The government accepted the deliverables and
issued a satisfactory performance rating.
I will now briefly walk through the timeline of events that
we provided in our written testimony.
Upon award of the contract in July 2017, AbleVets was
provided the existing CareT source code and supporting files
that were developed under a previous contractor. We made
modifications to this code to implement the additional
requirements documented in the VA-approved requirements
backlog.
In August of 2017, AbleVets began the efforts to migrate
data from the VA's transitional tool, CAT Rescue, into CareT.
The CAT Rescue effort was performed by a separate contract. CAT
Rescue contract experienced delays and eventually in
April 2018, VA decided not to deploy CAT Rescue. Based on
the new plan, our data migration requirement shifted to
migrating data from CAT instead of CAT Rescue. Because of this
change, VA exercised a 4-month cost modification to our
contract, resulting in the target date for completion of CareT
being extended to September 4, 2018.
In August of 2018, VA issued a new requirement consisting
of changes to a specific piece of functionality that had been
completed under the previous CareT contract. This piece of
functionality provided a portal interface to allow the veterans
and caregivers to complete online application.
When VA directed the implementation of this new requirement
in late August, they awarded AbleVets a 3-month cost-
modification to the contract, providing us to complete this new
requirement, and as a result extended the target date for
completion to December of 2018.
In late November of 2018, upon completion of the new portal
requirement, AbleVets had still remaining data migration to
complete. The migration effort had taken longer than estimated
due to the need to come up to speed on the CAT database, since
the data model was significantly different than the initially
planned CAT Rescue. We agreed to a no-cost extension to allow
time for the data migration to complete. This moved the target
date for completion to February 28th of 2019.
We began end to end user-acceptance testing in November of
2018. Throughout this testing, AbleVets worked closely with VA
to identify any issues identified by the testers and
categorized them as application defects or issues
representing additional requirements beyond the approved
baseline. We resolved defects in parallel with continued user-
acceptance testing.
In mid-January, we were informed by the VA program
management that they decided to pause further testing. During
this pause, we continued to resolve open defects that had been
identified to that point. By mid-February, AbleVets had
resolved the identified required defects and completed the data
migration efforts.
At that point, we were informed by VA that the Department
had chosen not to proceed with deployment of CareT and were not
going to exercise the sustainment optional task. Instead, the
exercised the ``Transition Out'' optional task, a 90-day
knowledge transfer and close-out period. We have successfully
performed transition activities, have had all contract
deliverables and invoices approved, and are on target to end
support on May 28th of 2019.
Thank you for allowing us to testify today and I look
forward to answering any questions you may have.
[The prepared statement of Dr. Wendell Ocasio appears in
the Appendix]
Ms. Brownley. Thank you, Dr. Ocasio. And Mr. Beecher, I now
recognize you for 5 minutes.
STATEMENT OF KEN BEECHER
Mr. Beecher. Good morning to all members of the House
Veteran Affairs Committee and Subcommittee. Thank you for the
opportunity to discuss VA's caregiver development
contract using the Salesforce platform. My name is Ken
Beecher and I am a Director at Acumen Solutions with
responsibility for the delivery and execution of our projects
at the U.S. Department of Veterans Affairs.
Acumen Solutions is a global consulting firm that helps
Fortune 1000 companies and government agencies anticipate and
respond to their customers' needs with innovative cloud-based
IT solutions. We were founded in 1999, and our primary focus is
to build mission-based systems that strengthen customer
relationships. As an industry leader, we partner with some of
the brightest innovators in cloud technology, such as
Salesforce, to create exceptional solutions for our customers.
It is our robust experience, innovative strategies, and a
commitment to see our customers succeed that make us a trusted
and proven leader in cloud computing.
Acumen Solutions is one of Salesforce's global strategic
partners, the highest tier in the Salesforce partner ecosystem.
We have completed over 1,800 Salesforce projects across our
commercial and public sector practices. We have worked in
nearly all the Federal cabinet agencies, including VA, and are
proud of our outstanding customer satisfaction rating. In
short: we pride ourselves in bringing value to our customers
and those they serve.
In September 2018, we were awarded a blanket purchase
agreement, called VA Enterprise Case Management Solutions or
VECMS. This vehicle provides the VA with easy access to Acumen
Solutions' professional services to implement Salesforce's
technology platform for any department within the VA. In March
2019, VA tasked Acumen Solutions with developing a level of
effort for a minimum viable product, the MVP, for the Caregiver
Record Management Application project, known as CARMA, under
the VECMS contract.
The Caregiver program is an important subset of the MISSION
Act, which was passed to improve the VA's ability to deliver
health care to our veterans; and CARMA is a subset of the
Caregiver program.
In April 2019, VA awarded Acumen Solutions the CARMA Phase
1 minimum viable product task order in the amount of $3.8
million to perform implementation and integration services. The
scope of the Phase 1 MVP is to replace the existing system, the
Caregiver Application Tracker, CAT, used by the Caregiver
Support Program with an application built on the Salesforce
platform. The new system will have improved functionality to
process and manage the applications, allow for manual
determination of eligibility, provide improved program
monitoring and tracking, and capture call records and referrals
by the caregiver support line.
On Monday, May 20th, after I had submitted my written
testimony to the Committee, the VA sent us a letter of intent
to exercise an optional task for CARMA Phase 2, Office of
Community Care Stipend Payments, in the amount of $1.8 million.
The scope of Phase 2 is to configure the CARMA module to
support the stipend payment calculation and associated tasks,
such as discharges, reinstatements, and reissues. We recognize
the VA's pressing need to develop and build its information
technology systems at less expense and with the Nation's
veterans at the center.
Acumen Solutions is using the Agile SCRUM software
development methodology to build the CARMA solution, which
enables us to rapidly build Salesforce solutions using
configuration while minimizing custom code. Furthermore, we
employ a user centered design methodology with close
consultation with the U.S. Digital Services, USDS, meaning that
we meet with users of the system to understand their needs and
pain points, and then create artifacts, such as prototypes and
journey maps, which are then shared with the configuration
team.
Our configuration team then works in a 2-week sprint,
ending with a demonstration of what was built for immediate
feedback. To mitigate risk, we provide VA end-users access to a
test environment with the latest application code, so they can
interact with and test the functionality independently. Each
sprint builds on the previous one until we reach a completed
solution. Our methodology lowers the risk to the VA and to the
taxpayers by developing pieces of the overall solution in bite
size increments. In addition, we work with the users throughout
to constantly confirm that each stage of development meets
their acceptance criteria.
Our success to date in configuring Salesforce and replacing
legacy systems at VA, are a result of collaboration with the VA
business office and its associated product owners, USDS, the VA
Digital Transformation Center, OI&T, the Technology Acquisition
Center, and the Salesforce Program and Business Architects
working at the VA.
Acumen Solutions is proud to partner with the VA and
Salesforce to provide an innovative, effective solution to
assist the VA on behalf of our Nation's veterans and their
caregivers.
Thank you. I look forward to your questions.
[The prepared statement of Ken Beecher appears in the
Appendix]
Ms. Brownley. Thank you, Mr. Beecher. Thank you for your
testimony and I now recognize Chairwoman Lee for 5 minutes.
Ms. Lee. Thank you. Thank you for being here. Mr. Beecher,
I wanted to ask you. When does the contract require you to
deliver the minimally viable product?
Mr. Beecher. In our task order, our goal is to implement
the solution by October 31st.
Ms. Lee. Is that contractually required?
Mr. Beecher. We have the flexibility to postpone that based
on Ms. Harris' critical success factors. So if those nine
components, and potentially more, happen then we can't be
beholden to if something gets delayed on VA's behalf.
Ms. Lee. So if the VA does not implement all nine of those
success factors, you are not contractually required to deliver-
Mr. Beecher. No.
Ms. Lee. Nothing?
Mr. Beecher. No, I misrepresented. No. It is important that
those nine factors are mitigated and managed too, but it
doesn't have to be 100 percent.
Ms. Lee. So when--contractually, when is the deadline for
you to deliver a product? You have none?
Mr. Beecher. We don't have a contractual-
Ms. Lee. It is a rolling--it is just a rolling deadline?
Mr. Beecher. Well, our goal is to deploy it by October
31st.
Ms. Lee. But it is not contractual? There is no
repercussions if you don't do it?
Mr. Beecher. No.
Ms. Lee. Okay. So what is your confidence level on the
ability to deliver by October 2019?
Mr. Beecher. I have a high degree of confidence that we
will be delivering.
Ms. Lee. A hundred percent? Ninety?
Mr. Beecher. I would say 95 percent, close to 100. Yes.
Ms. Lee. Will--so Salesforce, I just have a question about
what is their role in the implementation?
Mr. Beecher. So Salesforce has dedicated architects at the
VA that support each of the Salesforce projects there.
Ms. Lee. Okay. Dr. Ocasio, I wanted to switch to you. So
throughout your contract period, did the VA indicate any time
that your development was not going in the right direction?
Dr. Ocasio. Not in a broad sense. We had some issues that
were identified during the testing. That is kind of how testing
goes. You test so that you can see the issues. And we were
addressing them and categorizing them as these were really new
requirements. These were really misunderstanding of the
requirements. These were issues that were planned for a future
release, or these were the issues that we were going to fix,
and we would fix them as we would go along.
Ms. Lee. Okay. Can you explain the issues that were brought
up?
Dr. Ocasio. I mean, there is a variety of things. Like
sometimes they said we wanted this particular--if something is
in a queue and then you press a button, and then something
happens, and automatically it needs to be in this other queue,
specific business rules like that. Sometimes they said, ``Were
you expecting it in a different way?'' And that is when you do
the analysis to say, ``Wait a minute. This is how it was
supposed to be,'' or, ``No, this was a misunderstanding. Let's
go ahead and fix it.''
Ms. Lee. Okay. How much did the VA pay you before the
system was completely discarded?
Dr. Ocasio. Yeah. The total testimony at 3.5 million.
Ms. Lee. Okay. All right. I am finished. I will yield.
Ms. Brownley. Thank you, Ms. Lee. Mr. Lamb, I recognize you
for 5 minutes.
Mr. Lamb. Thank you, Madam Chairwoman. So Dr. Ocasio, were
you surprised when your relationship with the VA came to an end
earlier this year?
Dr. Ocasio. In para-government, we see often that plans
change, and things move in a different direction. The
government has all of the opportunity to make decisions in that
regard, and we completed the base period. So when there was a
decision to not to proceed, not completely surprising. It is
not necessarily absolutely expected. It certainly wasn't
expected like that, but we have seen changes like that before.
This is how the business is and we are at the pleasure of the
government of whatever they want to do.
Mr. Lamb. Were you given any indication throughout the
development process that they weren't happy with the product
you were creating?
Dr. Ocasio. Other than when there was a pause, obviously,
there seems to be something going on in terms of there was a
concern and they were looking at alternatives, but when we were
notified, I was--from the perspective of, ``We chose to go in a
different direction.''
Mr. Lamb. Do you believe that your product could have
handled the increased demand of the expansion of the Caregiver
program? We were given an estimate earlier that it could be
60,000 to 100,000.
Dr. Ocasio. Yeah. It was engineered to scale in that
regard.
Mr. Lamb. Okay. Thank you. Mr. Beecher, you have a goal of
October of this year. You are not bound to it legally for any
reason. Just in other situations that you have worked on, other
projects you have worked on, have you had contracts that have
bound you to a date for development of one of these IT
products?
Mr. Beecher. I will have to get back to you with that one.
I am not sure about as far as all of the projects that Acumen
has. I am just familiar with the projects that we have at VA.
Mr. Lamb. I just mean the ones that you have worked on.
Mr. Beecher. The ones I have worked, my apologies. There is
always flexibility with each of our contracts because of the
growing need and demand of those requirements. But at the end
of the day, we always try to deploy a minimum viable product by
that target date.
Mr. Lamb. Okay. I guess what I mean is I understand there
is always flexibility some time. Is the flexibility always on
the date or do they sometimes set a date that you are actually
required to have something finished by?
Mr. Beecher. Yes.
Mr. Lamb. They sometimes do do that.
Mr. Beecher. Based on time, yeah. For example, when we
deployed the views module within VA, which is a case management
solution, we had to get that deployed by I think February of
2018. Yeah, 2018.
Mr. Lamb. Okay. So based on what you expect to be finished
in October of this year, how quickly would an actual person,
say living in Pennsylvania, who qualifies for the expanded
benefit, how quickly after October 2019 would they actually see
the benefits given to them through your platform?
Mr. Beecher. So that's a very good question. So by the time
we deploy on October 31st, when the applications come in to the
caregiver support coordinator, that is when the process kicks
in. So I don't know exactly how long it is going to take for
that CSC person to enter the application in and do the pieces
of tasks that is needed, for example, doing the determination,
and visiting the home, and those sorts of responsibilities. So
I can't really say.
Mr. Lamb. But as far as the IT product goes, like you
finish it on October 31st. The VA is using it live on November
1st?
Mr. Beecher. Correct.
Mr. Lamb. Okay. Madam Chairwoman, those are my questions. I
yield back.
Ms. Brownley. Thank you, Mr. Lamb. Dr. Dunn.
Mr. Dunn. Thank you, Chairman Brownley. Mr. Beecher,
virtually all corporations that have a large customer or client
base use some sort of customer relations management software.
Your company specializes in helping people adopt Salesforce. Am
I correct? Do I understand that?
Mr. Beecher. Correct. We are a--we specialize in a variety
of different leading cloud solutions. Salesforce is the one
that is one of those technologies.
Mr. Dunn. Does your company use Salesforce?
Mr. Beecher. Yes, it does.
Mr. Dunn. Good. So this--I am familiar with this software.
It is actually fairly easy to use. Intuitive kind of use.
Easily adopted by the people in corporations I have worked in.
So other than the payroll management side of this thing, which
I don't think Salesforce does, but is a very, very standardized
corporate program and corporate function, what do you do with
Salesforce for all of your clients? You develop spreadsheets
for us or what?
Mr. Beecher. Very good question. So at VA, I will just
speak to my VA experience. So at VA, they use Salesforce for a
variety of different areas, some of those areas being case
management, correspondence management--
Mr. Dunn. That is all the typical things Salesforce does,
right?
Mr. Beecher. They do it very well, yes.
Mr. Dunn. So where do you fit into the thing? I mean when I
used Salesforce before, I called them, not you. What? Why?
Mr. Beecher. Well, we configure the Salesforce platform.
We're a services company.
Mr. Dunn. So you just tailor it to the corporation, the end
user?
Mr. Beecher. Yes, so we work with the end user to
understand the requirements and we then configure it based on
those requirements.
Mr. Dunn. Well, you got a hold of a big old tiger by the
tail here. I hope you manage to get it done in October. And
with that, I yield back, Madam Chair.
Ms. Brownley. Thank you, Dr. Dunn. Mr. Banks.
Mr. Banks. Thank you, Madam Chair. Dr. Ocasio, before I get
too deep into this, I want to ask you the most important, basic
question. Do you believe that CareT is capable of meeting VA's
needs now? And if not, what would need to happen to make it
capable?
Dr. Ocasio. I think CareT is able to meet the requirements
that we were given for this contract. It is not my place to say
whether those requirements, as done, are all that the VA needs.
I think that once you approach an agile development with the
new techniques like having a minimum viable product, and having
a dedicated product manager, you sometimes see that you have to
adjust your initial plans to what you really need.
So from the perspective of are we basing the decision on
how the requirements were written? I think absolutely it can be
done. We have all of those pieces. We have the--excuse me, the
CareT program has the portal, and has the payment calculations,
and have the ability to do the support line and so on and so
forth. So to the extent that that is sufficient, then yes, it
will be able to accomplish that.
Mr. Banks. Okay. Your product, CareT, went through a user
acceptance testing until February and your company's position
is that you fixed all the defects that were uncovered, does
that mean all possible defects were fixed or does it mean if
testing continued, there may be more defects uncovered and we
aren't sure what would happen with those?
Dr. Ocasio. I think that the whole purpose of having a
thorough test is to uncover issues. So to the extent that there
will be more testing, and in every program that is how you are
going to do it, you continue to find, and then you fix them in
a timely fashion. So there is no way to say that all of a
sudden because an abrupt test ended that there is nothing else
to be found.
Mr. Banks. Okay, Mr. Beecher, Salesforce is a cloud based,
customer relationship management or CRM platform. How is that
different from CAT and CareT, and how does a CRM system lend
itself to administering the caregiver program?
Mr. Beecher. Excellent question. Excuse me. So what
Salesforce is, Salesforce is a platform and so that platform
allows us to build solutions to meet those customers' needs.
When we met with the VA stakeholders in March, we got a very
good understanding of their business processes. We saw their
CAT demo. We talked about the strengths of the current systems,
the limitations, the deficiencies and what they would like to
see. And we were able to develop those requirements using the
Salesforce platform to meet those requirements.
Mr. Banks. So even though you are building the CARMA system
on a proven platform, there is obviously a lot of work
involved, given the timelines that VA presented. How much of
the functionality of the CARMA system already exists in the
generic Salesforce platform and how much are you creating?
Mr. Beecher. That is a good question. I would say that
Salesforce is a blank slate, if you will, of a commercial
solution that you are able to build. We use the out of the box
features to build those functionality. But having said that,
based on our experience at VA, we are able to leverage some of
those modules that we have previously built for other VA
offices into the CARMA module.
So for example, the MVI integration is something that we
can leverage and build on. And there are other modules as well
that we are leveraging.
Mr. Banks. So these caregiver systems are databases of
fewer than 50,000 people, as I understand. VA has much larger
databases than that, but that notwithstanding, these projects
are obviously difficult as VA is beginning its fourth attempt.
Where do you see the difficulty and the risk, and how is your
company going to perform better than that?
Mr. Beecher. Great question. And I am appreciative of Ms.
Harris' testimony before and seeing those nine components,
which I absolutely agree with. I mean, those are the
predominant risks of client engagement, participation, user
acceptance testing.
So to answer your question, according to our--using our
methodology, we do a 2-week sprint. At the end of those two
weeks, we give the user that ability to go into a test
environment and play with the functionality. And so one of the
big things that we have heard today is about UAT and waiting
too long. Well, we are actually doing it the week right after
the sprint, and they will have the ability to go into the
system afterwards.
Mr. Banks. Okay. Thank you. My time is expired.
Ms. Brownley. Thank you, Mr. Banks. And I will yield 5
minutes to myself.
Dr. Ocasio, first, let me say thank you for your service to
our country. I had a question for you. Your mission was to
develop an online application portal and I understand you
accomplished that. It is my understanding. So if you could talk
a little bit about the results of the portal. I think the key
question I wanted to ask is after the work that you had done,
do you think that your portal could have successfully received
applications for the caregiver program?
Dr. Ocasio. Yes, it could have.
Ms. Brownley. Yes?
Dr. Ocasio. Yes.
Ms. Brownley. Thank you very much. Mr. Beecher, you are our
white knight in shining armor. We are hoping really good things
to happen because this program needs to be completed and it
needs to get online. We are disappointed that Salesforce
couldn't be here so that we could get a sense from them. It is
always when people say they can't come, it gives you a bad
feeling that maybe they don't have good news to tell, and so
they are avoiding being here. I don't know what the situation
is.
But you have expressed a lot of confidence that you are on
the right track. Obviously, that is a first phase of a longer
phased process within CARMA. And I have been saying up here to
staff, I hope all of this is good CARMA, not bad CARMA. But in
terms of the additional steps that need to take place
throughout this, do you have any sense of timeline. The VA
obviously can't--won't commit to a timeline. Do you have any
sense of it at all?
Mr. Beecher. No. Our goal is to stay focused on the task at
hand with our first two phases.
Ms. Brownley. Pardon me?
Mr. Beecher. Our goal is to stay focused on those two
phases that we are signed up for as far as the task order.
Ms. Brownley. I see. So you have only been contracted for
two phases. I understand. Okay. Well, thank you very much. I
wonder if either one of you are aware of the Canadian system.
Canada has a comparable caregiver program system that works
very effectively is my understanding. And they have a robust
user facing portal that allows for the ability to apply online,
track status, appeal decisions, and communicate directly with
veteran case workers. Are either one of you familiar with that
system?
Dr. Ocasio. I am not familiar with it.
Ms. Brownley. No?
Mr. Beecher. Neither am I.
Ms. Brownley. Okay. Well, with that. I--members have needed
to leave. I need to go. So I want to thank both the panels for
being here. We will be staying in touch with you to understand
the progress because we are all very, very focused on this
October deadline. I thank you both for appearing before us
today. I think that we have gotten a lot of good information.
Now, we just need action and need this program up and running.
And with that, all members will have 5 legislative days to
revise and extend their remarks and include extraneous
materials. And so without objection, the Subcommittee stands
adjourned. Thank you.
[Whereupon, at 11:59 a.m., the Subcommittees were
adjourned.]
A P P E N D I X
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Prepared Statement of Steven Lieberman, M.D.
Introduction
Good morning Chairwoman Brownley, Chairwoman Lee, Ranking Member
Dunn, Ranking Member Banks, and Members of the Subcommittees. Thank you
for the opportunity to discuss VA's Caregivers Program relative to the
John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA
Maintaining Internal Systems and Strengthening Integrated Outside
Networks Act of 2018 (commonly referred to as the MISSION Act), and its
supporting Information Technology (IT) systems. I am accompanied today
by Dr. Elyse Kaplan, Deputy Director, VA Caregiver Support Program, and
Dr. Alan Constantian, Deputy Chief Information Officer, Account
Management Office and Account Manager for Health.
Caregivers play a critical role in the United States health care
system. VA is leading the country in providing unprecedented benefits
and services to caregivers in support of Veterans, knowing that
providing care takes a toll on one's physical, psychological, and
financial health. Caregivers enable Veterans to maintain their highest
level of independence and remain in their homes and communities for as
long as possible. The MISSION Act expands comprehensive services and
supports to family caregivers of eligible Veterans of all service eras.
MISSION Act and PCAFC Transformation
The Program of Comprehensive Assistance for Family Caregivers
(PCAFC) is currently limited to eligible Veterans who incurred or
aggravated a serious injury in the line of duty on or after September
11, 2001, and their family caregivers, who have benefited greatly from
the services provided through this program. Under the MISSION Act,
PCAFC will expand to include eligible Veterans of earlier service eras
once VA certifies to Congress that we have fully implemented the
required IT system. The expansion will occur in two phases beginning
with eligible Veterans who incurred or aggravated a serious injury in
the line of duty on or before May 7, 1975. Two years later, PCAFC will
expand to include eligible Veterans injured during the remaining eras
of service. VA is pleased to expand PCAFC to more family caregivers of
eligible Veterans of all service eras.
VA was working to improve the administration of PCAFC in response
to concerns about inconsistency before the MISSION Act was enacted and
now we have increased those efforts to support the program's expansion.
The Caregiver Support Program (CSP) has strengthened its overall
governance by requiring every Veterans Integrated Service Network
(VISN) Director to designate a VISN Lead who is charged with monitoring
the administration of PCAFC across the VISN; providing guidance,
coaching, and support to Caregiver Support Coordinators (CSC) within
the VISN; and ensuring compliance with national policy and procedures.
In cases where a VISN Lead is also a Caregiver Support Coordinator,
VISN Directors are required to ensure another identified point of
contact at the VISN Office.
VA recognizes that the current eligibility criteria and assessment
for PCAFC are complex and is, therefore, engaged in process improvement
efforts to promote accurate and consistent decision making. The
Caregiver Support Program deployed a mandatory annual refresher
training for CSCs and VISN Leads in March 2019 and followed this with
small group discussions to provide further opportunity for
clarification and coaching. Additionally, clinical eligibility training
for PCAFC providers is currently in development and will serve to
further enhance accurate decision-making.
VA has amended Veterans Health Administration (VHA) Directive
1152(1), Caregiver Support Program, to include 14 Standard Operating
Procedures (SOP) that provide further guidance to field based staff
responsible for administering local CSPs. SOP topics include required
orientation, required training, and other operationalizing procedures
governing PCAFC such as communicating roles, responsibilities, and
requirements to those applying for PCAFC. National training on these
SOPs was provided to CSCs and VISN leads in October 2018.
VA has heard concerns from Veterans, caregivers, and other
stakeholders about PCAFC inconsistencies. We have done a great deal of
work to better train and equip our staff with the tools needed to
promote increased standardization; however, more needs to be done. VA
understands the importance of changing elements of the program that
will foster consistency, improve transparency, and provide support and
services to eligible Veterans and their caregivers, as intended. To
achieve this, VA is pursuing regulatory changes to improve the current
PCAFC and expand PCAFC eligibility and services as required by the
MISSION Act. Changes under consideration include modifying the stipend
payment methodology; establishing a standardized timeframe for
eligibility reassessments; and redefining aspects of the eligibility
requirements, such as the definition of serious injury, to provide more
clarity for VA staff and more importantly, Veterans and their family
caregivers. As part of PCAFC expansion, VA also considered reducing the
number of need tier levels. Currently there are three tiers, which
generally correspond to low, moderate, and high degrees of need. Any
changes to PCAFC regulations are subject to notice and comment
rulemaking.
As we pursue the rulemaking required to implement the MISSION Act,
VA has pursued opportunities to engage Veterans, subject matter
experts, Veterans Service Organizations (VSO), caregivers, and other
stakeholders. In November 2018, a notice was published in the Federal
Register seeking public comments on how to improve PCAFC and implement
certain changes to PCAFC that are required by the MISSION Act. Feedback
included the importance of clear definitions, for example personal care
services, the impact of cognitive impairment and standardization of
eligibility. Additionally, in March and April 2019, VA held meetings
with various VSOs to discuss PCAFC and the MISSION Act. Discussion
topics included the definitions related to PCAFC eligibility, the tier
system, and the revocation and transition of participants from PCAFC. A
listening session with a small group of caregivers currently
participating in the PCAFC occurred on April 26, 2019. This listening
session sought input on the delivery of legal services and financial
planning services, as authorized by the MISSION Act.
Any proposed changes to the regulations governing PCAFC, including
rulemaking to implement expanded eligibility and services as directed
by the MISSION Act, will include an impact analysis that provides,
among other things, projected costs and impact on eligible Veterans and
caregivers. Regardless of pending regulatory changes impacting
eligibility determinations, consistent decision making and transparent
communication, that includes input from the Veteran and family
caregiver, will remain an integral part of our processes.
IT Development Process
VA acknowledges that we have faced technology challenges around the
Caregiver Support Program in the past. In response to these challenges,
the VA Office of Information Technology and VHA agreed to execute a
strategic pivot away from a custom developed to a commercial off-the-
shelf (COTS) system to better support the program's current and future
needs and business requirements.
This pivot included simplifying the business requirements coupled
with selecting the right COTS software platform which could be
configured to meet the specific requirements of VA's Caregiver program.
Additionally, VA shifted from an approach where all desired system
requirements were delivered in a single release to one where useful
functional components could be delivered into production for use by the
program office incrementally. This is the agile development approach to
software development widely adopted across the private and public
sectors. We also designated a full-time Product Manager to ensure that
we build a highly functioning product in an iterative manner; have the
proper oversight over implementation; and ensure future expansion of
the program. Currently, VA is actively engaging in planning for data
migration and integration with other VA systems, such as the Master
Veteran Index, the Enrollment System, the Financial Management System,
and the Benefit Gateway System.
The original effort to develop an IT solution for the current
program was intended to support administrative processing of
applications, automate stipend payments to Caregivers, and provide
systems support for Caregiver Support Services and the Caregiver
Support Line. However, because of defects arising during user
acceptance testing of the CareT product, testing was paused in early
January 2019. VA reviewed its options for implementing a robust
Caregiver IT solution in January and February 2019 and chose to take a
new direction it believes will provide a firmer foundation for systems
support for the Caregiver program in the long run. We chose the
commercially available Salesforce solution as an improved technological
platform for our systems solution. We also committed to a more
intentionally agile development approach, with incremental deliveries
of capability into production. Finally, we assigned and empowered a
Product Manager for the new approach who will guide the agile
development process of the newly named Caregiver Record Management
Application (CARMA). The Product Manager is responsible for the backlog
of IT work and will ensure the program's prioritized requirements are
executed in a disciplined agile manner through incremental releases.
The projected outcome is the delivery of software and a database on a
scalable computing platform to meet the requirements of the MISSION
Act.
CARMA will replace the existing Caregiver Application Tracker (CAT)
and will have multi-level functionality, including the ability to:
Track and manage PCAFC applications, including approvals,
denials, and appeals;
Support the administration of PCAFC and monitoring the
well-being of participants in PCAFC;
Track calls made to the Caregiver Support Line (CSL), as
well as caregiver referrals to local medical centers for additional
assistance;
Process stipend payments to family caregivers in PCAFC;
and
Improve reporting capabilities.
The MISSION Act requires that this new system easily retrieve data
that allows all aspects of PCAFC, including workload trends (at the
medical center and aggregate levels), be assessed and comprehensively
monitored. Further, the system must have the ability to manage
caregiver data that exceeds the number of caregivers that the Secretary
of Veterans Affairs expects to apply for PCAFC, as well as the ability
to integrate the system with other relevant VHA IT systems.
Delivery Schedule
The first release of CARMA is expected to be launched in quarter 1
of Fiscal Year 2020. It will replace much of the CAT functionality as
it currently exists and feature increased data integrity, to allow for
improved oversight at the medical center level. The second release of
CARMA, anticipated in January 2020 (exact date to be determined) will
automate the processing of stipend payments to caregivers. Subsequent
releases of CARMA and associated efforts will modify systems with which
CARMA will interface (e.g. the Computerized Patient Record System; the
Enrollment and Eligibility System; and Veterans Information Systems and
Technology Architecture VistA components) and deliver other program
office requirements needed to fully support PCAFC expansion.
Conclusion
VA supports the expansion of PCAFC and recognizes the sacrifice and
value of Veterans' family caregivers. Expanding PCAFC eligibility under
the MISSION Act will allow VA to support family caregivers of Veterans
of all eras of service. Given the critical role caregivers play in
providing for Veterans, VA is committed to the development of robust
policies and systems that support them. We are committed to rebuilding
the trust of Veterans and will work hard to continue the improvements
we have made thus far. Your continued support is essential to providing
this care for Veterans and their families. This concludes my testimony.
My colleagues and I are prepared to answer any questions.
Carol C. Harris
VA HEALTH IT
Use of Acquisition Best Practices Can Improve Efforts to Implement a
System to Support the Family Caregiver Program
Chairs Lee and Brownley, Ranking Members Banks and Dunn, and
Members of the Subcommittees:
Thank you for the opportunity to participate in today's hearing
regarding the Department of Veterans Affairs' (VA) efforts to implement
an information technology (IT) system to support the management and
execution of its Program of Comprehensive Assistance for Family
Caregivers (Family Caregiver Program).
To provide greater support for caregivers of post-9/11 veterans,
Congress and the President enacted legislation in May 2010 requiring VA
to establish a program to assist caregivers with the rigors of caring
for seriously injured veterans.\1\ In May 2011, the Veterans Health
Administration (VHA), which operates VA's health care system,
established the Family Caregiver Program at each of its VA medical
centers (VAMC) across the United States.
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\1\ See Caregivers and Veterans Omnibus Health Services Act of
2010, Pub. L. No. 111-163, 124 Stat. 1130 (May 5, 2010) (codified at 38
U.S.C. Sec. 1720G). The term "caregiver" in this testimony refers to
the individual that VA approved to serve as the veteran's primary
caregiver. A veteran may have up to three approved caregivers at a time
under the program, see 38 C.F.R. Sec. 71.25(a)(1), but only the
primary caregiver is eligible for the full range of services authorized
by the statute. 38 U.S.C. Sec. Sec. 1720G(a)(3)(A), (a)(7)(B).
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At that time, the department implemented an IT system, called the
Caregiver Application Tracker (CAT), to help support the program.
However, we reported in September 2014 that CAT, which is still in use
today, had limitations and recommended that VA expedite the
implementation of a replacement system.\2\
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\2\ GAO, VA Health Care: Actions Needed to Address Higher-Than-
Expected Demand for the Family Caregiver Program, GAO-14-675
(Washington D.C.: Sept. 18, 2014).
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As you requested, my statement today summarizes findings from our
September 2014 report that discussed VA's implementation of the Family
Caregiver Program. This statement also includes relevant information
that VA provided on its actions toward addressing our prior
recommendation. Further, my statement discusses critical success
factors related to major IT acquisitions identified in our prior
work.\3\ We have previously reported that these success factors could
enhance the likelihood that an IT acquisition will be successful. The
reports cited throughout this statement include detailed information on
the scope and methodology of our prior reviews.
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\3\ GAO, Information Technology: Critical Factors Underlying
Successful Major Acquisitions, GAO-12-7 (Washington, D.C.: Oct. 21,
2011).
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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
VHA's Family Caregiver Program is designed to provide support and
services to family caregivers of post-9/11 veterans who have a serious
injury that was incurred or aggravated in the line of duty. The program
provides approved primary family caregivers with a monthly financial
stipend as well as training and other support services, such as
counseling and respite care.\4\
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\4\ Other approved caregivers-referred to as secondary family
caregivers-may be eligible for training, counseling, and certain
lodging and subsistence.
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The Family Caregiver Program has a series of eligibility
requirements that must be satisfied in order for family caregivers to
be approved.
To meet the program's initial eligibility criteria, the
veteran seeking caregiver assistance must have a serious injury that
was incurred or aggravated in the line of duty on or after September
11, 2001.\5\ According to the program's regulations, a serious injury
is any injury, including traumatic brain injury (TBI), psychological
trauma, or other mental disorder, that has been incurred or aggravated
in the line of duty and renders the veteran or servicemember in need of
personal care services.
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\5\ The applicant could also be a servicemember who is undergoing
medical discharge from the military.
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The veteran must be in need of personal care services for
a minimum of 6 continuous months based on any one of the following
clinical eligibility criteria: (1) an inability to perform one or more
activities of daily living, such as bathing, dressing, or eating;\6\
(2) a need for supervision or protection based on symptoms or residuals
of neurological or other impairment or injury such as TBI, post-
traumatic stress disorder, or other mental health disorders; (3) the
existence of a psychological trauma or a mental disorder that has been
scored by a licensed mental health professional, with a Global
Assessment of Functioning score of 30 or less,\7\ continuously during
the 90-day period immediately preceding the date on which VHA initially
received the application; or (4) the veteran has been rated 100 percent
service connected disabled for a qualifying serious injury and has been
awarded special monthly compensation that includes an aid and
attendance allowance.\8\
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\6\ The activities of daily living that veterans may need
assistance with to qualify for the program include dressing or
undressing; bathing; grooming; toileting; eating; mobility such as from
the bed to a chair; and frequently adjusting a prosthetic or orthopedic
device that cannot be done without assistance.
\7\ The Global Assessment of Functioning assessment is a well-
established mental health examination that uses a score of zero to 100
to determine an individual's ability to function psychologically and
socially. An individual who has been assessed as having a psychological
trauma or mental disorder and has been scored at 30 or less generally
requires a higher level of care that would include constant
supervision.
\8\ VA's Aid & Attendance is a financial benefit for veterans who
require assistance from a caregiver. It can be added to a veteran's
existing pension if the veteran requires assistance with activities of
daily living or for safety. Veterans who are bedridden, severely
visually impaired, or reside in a nursing home due to mental or
physical incapacity also may qualify.
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To be considered competent to care for the veteran,
family caregivers must meet certain requirements including (1) having
the ability to communicate and follow details of the treatment plan and
instructions related to the care of the veteran; (2) not determined by
VA to have abused or neglected the veteran; (3) being at least 18 years
of age; and (4) either being a family member-such as a spouse, son or
daughter, parent, step-family member, or extended family member-or an
unrelated person who lives or will live full-time with the veteran.
Family caregivers must also complete required training
before being approved for the program.
Family Caregiver Program Organizational Structure
VHA's Caregiver Support Program office is responsible for
developing policy and providing guidance and oversight for the Family
Caregiver Program. It also directly administers the program's stipend,
provides support services such as a telephone hotline and website, and
arranges coverage through the Civilian Health and Medical Program of
the Department of Veterans Affairs (CHAMPVA) for eligible caregivers if
they have no other coverage.\9\
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\9\ Primary family caregivers approved for the Family Caregiver
Program qualify for CHAMPVA if they are not eligible for TRICARE and
are not entitled to care or services under a health plan contract (as
defined in 38 U.S.C. Sec. 1725(f)), including Medicare or employer
provided health insurance. Caregivers covered by CHAMPVA can receive
medical services from community providers or, when available, from
VAMCs.
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Further, the office provides funding to VAMCs to cover certain
program costs. These costs may include the salaries of the caregiver
support coordinators (CSC), who implement and administer the Family
Caregiver Program at the local VAMC level, and the costs VAMCs incur
for having their clinical staff, such as nurses, conduct the program's
required in-home visits to approved caregivers and their veterans.
CSCs are generally licensed social workers or registered nurses,
and they have both clinical and administrative responsibilities. Their
clinical responsibilities may include identifying and coordinating
appropriate interventions for caregivers or referrals to other VA or
non-VA programs, such as mental health treatment, respite care, or
additional training and education. Their administrative
responsibilities may include responding to inquiries about the program,
overseeing the application process, entering information about
applications and approved caregivers into IT systems, and facilitating
the processing of appeals.
As of May 2014, there were 233 CSCs assigned to 140 VAMCs or health
care systems across the country.\10\ Additionally, each regional VISN
office has a VISN CSC lead for the program, who provides guidance to
CSCs and helps address their questions or concerns.
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\10\ While CSCs administer the Family Caregiver Program at 151 VA
facilities, they are assigned to 140 VAMCs or health care systems,
which may include more than one VA facility. We present program
statistics based on CSC assignments because that is how they are
tracked by the Caregiver Support Program office.
GAO Has Previously Reported on the Family Caregiver Program IT System
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Limitations
CAT, which was deployed in May 2011, is a web-based system that was
designed to facilitate the exchange of information about approved
caregivers between VAMCs and other VHA entities. Such entities include
the Health Administration Center, which processes the caregiver stipend
payments and administers CHAMPVA.
In 2014, we reported that the Caregiver Support Program office was
not able to easily retrieve data from CAT that would allow officials to
better assess workload trends at individual VAMCs-such as the length of
time applications are delayed or the timeliness of home visits-even
though these data were already captured in the system.\11\ Caregiver
Support Program officials only retrieved workload data on an ad hoc,
as-needed basis, which limited their ability to assess the scope and
extent of workload problems comprehensively at individual VAMCs and on
a system-wide basis. Program officials also expressed concern about the
reliability of the system's data.
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\11\ GAO-14-675.
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As we noted in our report, program officials also identified the
need for a more capable and flexible system that could interface with
other departmental systems. The officials told us that they had taken
initial steps to obtain another IT system to support the Family
Caregiver Program; however, the officials were not sure how long it
would take to implement the system. Accordingly, we recommended that VA
expedite the process for identifying and implementing a system that
would fully support the Family Caregiver Program.
VA concurred with our recommendation and subsequently began taking
actions in 2015 to implement a replacement system. These actions
included taking steps toward implementing short-term improvements to
CAT that were to be followed by the implementation of a long-term
replacement system. The recommendation continues to remain open.
Statute Directs VA to Implement an IT System to Support the Family
Caregiver Program
The John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA
Maintaining Internal Systems and Strengthening Integrated Outside
Networks Act of 2018 (VA MISSION Act), which was enacted in June 2018,
included provisions directing VA to implement an IT system to support
the Family Caregiver Program and the incremental expansion of program
eligibility.\12\ Specifically, the Act required VA to implement an IT
system to fully support the Family Caregiver Program by October 1,
2018. According to the act, the system is to allow for data assessment
and comprehensive monitoring of the program. In particular, the system
is to have, among other things, the ability to (1) retrieve data to
monitor workload trends at the medical center and aggregate levels; (2)
manage an increased number of caregivers as the program expands; and
(3) integrate with other relevant IT systems at VHA.
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\12\ Pub. L. No. 115-182, Sec. Sec. 161-163, 132 Stat. 1438-1443
(2018). The VA MISSION Act requires an incremental expansion of
eligibility for the Family Caregiver Program. Specifically, within 2
years of the VA Secretary certifying the IT system for the Family
Caregiver Program, VHA is to expand program eligibility to caregivers
of veterans with a serious injury incurred or aggravated in the line of
duty on or before May 7, 1975 or on or after September 11, 2001. Two
years after this initial expansion of eligibility, VHA is to further
expand program eligibility to include veterans with a serious injury
incurred or aggravated in the line of duty and is in need of personal
care services as specified in the statute.
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The act also stated that VA was to submit an initial report to
Congress regarding the status of the planning, development, and
deployment of this system within 90 days of enactment of the VA MISSION
Act, and that the department is to submit a final report to Congress by
October 1, 2019. The final report is to include a certification by the
VA Secretary that the system has been implemented, along with a
description of how the Secretary is using the system to monitor the
workload of the program.
VA Has Not Yet Implemented an IT System That Effectively Supports the
Family Caregiver Program
Although we previously recommended that VA expedite implementation
of a replacement for CAT, and the MISSION Act directed the department
to implement an IT system to support the Family Caregiver Program, VA
has not yet been successful in its multiple efforts to implement such a
system. Specifically, VA has faced a number of difficulties in
developing and implementing short-term improvements as well as a long-
term replacement system for CAT.
In July 2015, VHA and the Office of Information and Technology
(OIT) initiated a joint acquisition project, called CAT Rescue, to
update CAT and improve the system's data reliability.\13\ However, the
department reported in January 2017 that this project had experienced
delays and identified a large number of defects during system testing.
VA terminated the project in April 2018 before any new system
capabilities were implemented.
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\13\ OIT, under the leadership of the Assistant Secretary for
Information and Technology/Chief Information Officer, manages most IT-
related functions at VA.
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A companion project to CAT Rescue that VA initiated in September
2015 was to develop the Caregivers Tool (CareT), a new system intended
to be a long-term replacement for CAT. As envisioned, this system was
to use the improved data from CAT Rescue while also adding new system
capabilities. However, the user acceptance testing of CareT identified
the need for the department to develop more system capabilities than
originally planned. Further, the department determined that the time
period needed to perform additional system development would have
extended beyond the term of the development contract, which ended in
April 2017.
VA subsequently awarded a new CareT development contract in July
2017. However, after additional system development, the department
determined during user acceptance testing that the system was not
performing as expected and implementation of CareT was further delayed.
In October 2018, the department reported to congressional committees
that implementing a system to fully support the Family Caregiver
Program by the VA MISSION Act deadline was not feasible. Subsequently,
the department determined that CareT was not a viable solution and VHA
and OIT terminated work on the system in February 2019.
VHA and OIT began a third effort in March 2019 to acquire a
replacement system that is to be based on an existing commercial
product. According to OIT officials, the new IT solution, referred to
as the Caregiver Record Management Application (CARMA), is intended to
replace CAT. However, the department has not yet established a date for
completing CARMA.
Thus, VA's efforts to implement an IT system that supports the
Family Caregiver Program have been continuing with no end in sight. We
have ongoing work to further evaluate the status and progress of the
department's efforts to implement a system to support the Family
Caregiver Program consistent with the VA MISSION Act requirements.
Figure 1 provides a timeline of the various IT projects that VA has
undertaken to support the program.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Critical Factors Underlying Successful IT Acquisitions
Our prior work has determined that successfully overcoming IT
acquisition challenges can best be achieved when critical success
factors are applied.\14\ Specifically, we reported in 2011 on common
factors critical to the success of IT acquisitions, based on seven
agencies having each identified the acquisition that best achieved the
agency's respective cost, schedule, scope, and performance goals. These
factors remain relevant today and can serve as a model of best
practices that agencies can apply to enhance the likelihood that the
acquisition of an IT system such as CARMA will be successfully
achieved.
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\14\ GAO-12-7.
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Among the agencies' seven IT investments, agency officials
identified nine factors as having been critical to the success of three
or more of the seven investments. These nine critical success factors
are consistent with leading industry practices for IT acquisition. The
factors are:
Active engagement of program officials with stakeholders.
Qualified and experienced program staff.
Support of senior department and agency executives.
Involvement of end users and stakeholders in the
development of requirements.
Participation of end users in testing system
functionality prior to formal end user acceptance testing.
Consistency and stability of government and contractor
staff.
Prioritization of requirements by program staff.
Regular communication maintained between program
officials and the prime contractor.
Sufficient funding.
Officials for all seven selected investments cited active
engagement with program stakeholders-individuals or groups (including,
in some cases, end users) with an interest in the success of the
acquisition-as a critical factor to the success of those investments.
Agency officials stated that stakeholders, among other things, reviewed
contractor proposals during the procurement process, regularly attended
program management office sponsored meetings, were working members of
integrated project teams,\15\ and were notified of problems and
concerns as soon as possible. Further, officials from two investments
noted that actively engaging with stakeholders created transparency and
trust, and increased the support from the stakeholders.
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\15\ The Office of Management and Budget defines an integrated
project team as a multi-disciplinary team led by a project manager
responsible and accountable for planning, budgeting, procurement, and
life-cycle management of the investment to achieve its cost, schedule,
and performance goals. Team skills include budgetary, financial,
capital planning, procurement, user, program, architecture, earned
value management, security, and other staff as appropriate.
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Additionally, officials for six of the seven selected investments
indicated that the knowledge and skills of the program staff were
critical to the success of the program. This included knowledge of
acquisitions and procurement processes, monitoring of contracts, large-
scale organizational transformation, Agile software development
concepts,\16\ and areas of program management such as earned value
management and technical monitoring.
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\16\ Agile software development is not a set of tools or a single
methodology, but a philosophy based on selected values, such as
prioritizing customer satisfaction through early and continuous
delivery of valuable software; delivering working software frequently,
from every couple of weeks to every couple of months; and making
working software the primary measure of progress.
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Finally, officials for five of the seven selected investments
identified having the end users test and validate the system components
prior to formal end user acceptance testing for deployment as critical
to the success of their program. Similar to this factor, leading
guidance recommends testing selected products and product components
throughout the program life cycle.\17\ Testing of functionality by end
users prior to acceptance demonstrates, earlier rather than later in
the program life cycle, that the functionality will fulfill its
intended use. If problems are found during this testing, programs are
typically positioned to make changes that would be less costly and
disruptive than ones made later in the life cycle.
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\17\ See, for example, Carnegie Mellon Software Engineering
Institute, Capability Maturity Modelr Integration for Acquisition
(CMMI-ACQ), Version 1.3 (November 2010).
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In conclusion, VA has invested considerable time in multiple
efforts toward improving and replacing its IT system to better serve
the Family Caregiver Program. However, even with these efforts, the
department has not yet implemented a system and the program is not
prepared for expansion. Going forward, it is important that VA take
steps to improve its efforts to implement a replacement IT system for
the Family Caregiver Program. In this regard, the department could
benefit from applying critical success factors we previously reported
as leading to successful federal IT acquisitions. These factors can
serve as a model of best practices that the department can apply to
enhance the likelihood that its effort to replace the IT system for the
Family Caregiver Program will be successful.
Chairs Lee and Brownley, Ranking Members Banks and Dunn, and
Members of the Subcommittees, this completes my prepared statement. I
would be pleased to respond to any questions that you may have.
GAO Contact and Staff Acknowledgments
If you or your staffs have any questions about this testimony,
please contact Carol C. Harris, Director, Information Technology
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), Rebecca Eyler, Jacqueline Mai, Monica Perez-Nelson, Scott
Pettis, and Jennifer Stavros-Turner (Analyst in Charge).
GAO HIGHLIGHTS
Why GAO Did This Study
To provide greater support for caregivers of post-9/11 veterans,
Congress and the President enacted legislation requiring VA to
establish a program to assist caregivers with the rigors of caring for
seriously injured veterans. In May 2011, the Veterans Health
Administration (VHA), which operates VA's health care system,
established the Family Caregiver Program at each of its VA medical
centers across the United States. At that time, the department
implemented an IT system, called CAT, to help support the program.
Subsequently, the VA MISSION Act was enacted in June 2018, requiring VA
to implement an IT system to fully support the Family Caregiver Program
by October 1, 2018. Further, VA's Secretary is to certify the system by
October 1, 2019.
GAO was asked to discuss its September 2014 report that examined
how VHA is implementing the Family Caregiver Program. In addition, the
statement includes relevant information VA provided on its actions
toward addressing GAO's prior recommendation. The statement also
discusses critical success factors related to IT acquisitions as
identified in GAO's prior work. The reports cited throughout this
statement include detailed information on the scope and methodology of
GAO's prior reviews.
What GAO Recommends
GAO recommended in 2014 that VA expedite the process for
identifying and implementing an IT system that would fully support the
Family Caregiver Program. VA concurred with the recommendation and
subsequently began taking steps to implement a replacement system. The
recommendation remains open.
What GAO Found
In September 2014, GAO reported on the Department of Veterans
Affairs' (VA) Program of Comprehensive Assistance for Family Caregivers
(Family Caregiver Program) and found that the program office had
limitations with its information technology (IT) system-the Caregiver
Application Tracker (CAT). Specifically, the program did not have ready
access to workload data that would allow it to monitor the effects of
the program on VA medical centers' resources. VA has initiated various
projects since 2015 to implement a new system, but has not yet been
successful in its efforts. (See figure.) Specifically, in July 2015 VA
initiated a project to improve the reliability of CAT's data, called
CAT Rescue. However, the department reported in January 2017 that it
had identified numerous defects during system testing. The project
ended in April 2018 before any new system capabilities were
implemented. A companion project was initiated in September 2015 to
develop the Caregivers Tool (CareT), a new system intended to replace
CAT. The CareT project was expected to use improved data from CAT
Rescue, while also adding new system capabilities. However, the user
acceptance testing of CareT identified the need for the department to
develop more system capabilities than originally planned. Further, VA
reported that implementing a system by October 1, 2018, as specified in
the Maintaining Internal Systems and Strengthening Integrated Outside
Networks Act of 2018 (MISSION Act), was not feasible. Subsequently, VA
terminated CareT in February 2019. The department initiated another
project in March 2019 to implement a new system, the Caregiver Record
Management Application (CARMA). GAO has ongoing work to evaluate the
department's efforts to implement an IT system to support the Family
Caregiver Program as required by the MISSION Act.
FIGURE ONE HERE ALSO
GAO's prior work has determined that successfully overcoming IT
acquisition challenges can best be achieved when critical success
factors are applied. These factors can serve as a model of best
practices that VA could apply to enhance the likelihood that the
acquisition of a replacement IT system for the Family Caregiver Program
will be successfully achieved. Examples of these critical success
factors include, maintaining active engagement of program officials
with stakeholders, involving end users and stakeholders in the
development of requirements, and ensuring participation of end users in
testing system functionality prior to formal end user acceptance
testing.
Wendell Ocasio, MD
Chairwoman Brownley, Chair Lee, Ranking Member Dunn, Ranking Member
Banks, and distinguished Members of the Subcommittees, thank you for
this opportunity to testify today regarding VA's Caregiver Tool
development. AbleVets LLC is a certified Service-Disabled Veteran Owned
Small Business specializing in cybersecurity, agile engineering,
analytics and technology enablement solutions for government.
AbleVets was awarded the "Caregiver Tool Development" (CareT)
contract (VA11816F10090010) on July 5, 2017. The delivery requirement
for the 10-month Base Period was for AbleVets to, starting with an
existing CareT application code base, implement a defined set of
additional application requirements, migrate data from Caregiver
Application Tracker (CAT) Rescue into the CareT product, test the final
product, and deploy into production. The two 12-month Option Periods
were focused solely on sustaining the CareT application once deployed
into production.
Ultimately, AbleVets was obligated $3.5M over a 23-month period,
successfully completing and delivering the Base Period requirements.
The government accepted all deliverables and issued a Satisfactory
performance rating. We are currently performing the Optional Task
"Transition Out" requirements prior to the contract close-out on May
28, 2019. A more detailed summary of the work AbleVets performed is
below:
Upon award of the contract in July 2017, AbleVets was provided the
existing CareT source code and supporting files that were developed
under a previous contractor. We made modifications to this code to
implement the additional requirements documented in the VA-approved
requirements backlog.
In August 2017, AbleVets began efforts to migrate data from VA's
transitional Caregiver management tool called, CAT Rescue, into CareT.
The CAT Rescue effort was performed by a separate contract/contractor.
The CAT Rescue contract experienced delays and eventually in April
2018, VA decided not to deploy CAT Rescue. Based on the new plan to
transition VA's production caregiver tool called CAT directly to CareT,
our data migration requirement shifted to migrate data from CAT
instead. Because of this change, VA exercised a 4-month cost-
modification to the AbleVets CareT contract, resulting in the target
date for completion of CareT being extended to September 4, 2018.
In August 2018, the VA program manager issued a new requirement
consisting of changes to a specific piece of functionality that had
been completed under the previous CareT contract. This piece of
functionality provided a `portal' interface to allow veterans and
caregivers to complete the application online, which would then be
transferred directly to the VA staff for adjudication. As VA directed
the implementation of this new requirement in late August, they awarded
AbleVets a 3-month cost-modification to AbleVets' CareT contract,
providing time for us to complete this new requirement. The result of
this contract modification was to extend the target date for completion
of CareT to December 4, 2018.
In late November 2018, upon completion of the new portal
requirement, AbleVets had remaining data migration to complete. The
migration effort had taken longer than estimated due to the need to
come up to speed on the CAT database since the data model was
significantly different than the initially planned CAT Rescue. VA and
AbleVets agreed to a no-cost extension to allow time for the data
migration to complete. At that time, the new target date for completion
of CareT was moved to Feb 28, 2018.
End to end user-acceptance testing began on the CareT application
November 2018. Throughout this testing, AbleVets worked closely with VA
to identify any issues identified by the testers and categorize them as
application defects or issues representing additional requirements
beyond the approved baseline. AbleVets resolved defects in parallel
with continued user-acceptance testing.
In mid-January 2019, AbleVets was informed by VA program management
that they decided to pause further testing. During this pause, AbleVets
continued to resolve open defects that had been identified to that
point. By mid-February 2019, AbleVets had resolved all identified
defects and completed the data migration efforts. At that point we were
informed by VA that the Department had chosen not to proceed with
deployment of CareT, and thus were not going to exercise the
sustainment Optional Years. Instead, VA exercised the "Transition Out"
Optional Task - a 90-day knowledge transfer and close-out period. We
have successfully performed Transition Activities, have had all
contract deliverables and invoices approved, and are on-target to end
support on May 28, 2019.Thank you.
Ken Beecher
Good morning to all members of the House Veterans Affairs Committee
and Subcommittees. Thank you for the opportunity to discuss VA's
Caregiver development contract using the Salesforce platform. My name
is Ken Beecher and I'm a Director at Acumen Solutions with
responsibility for the delivery and execution of our projects at the US
Department of Veterans Affairs.
Acumen Solutions is a global consulting firm that helps Fortune
1000 companies and government agencies anticipate and respond to their
customers' needs with innovative cloud-based IT solutions. We were
founded in 1999, and our primary focus is to build mission-based
systems that strengthen customer relationships. As an industry leader,
we partner with some of the brightest innovators in cloud technology,
such as Salesforce, to create exceptional solutions for our customers.
It is our robust experience, innovative strategies, and a commitment to
see our customers succeed that make us a trusted and proven leader in
cloud consulting.
Acumen Solutions is one of Salesforce's Global Strategic Partners,
the highest tier in the Salesforce partner ecosystem. We have completed
over 1,800 Salesforce projects across our commercial and public sector
practices. We have worked in nearly all the Federal cabinet agencies -
including the VA - and are proud of our outstanding customer
satisfaction rating. In short: we pride ourselves in bringing value to
our customers and those they serve.
In September 2018, we were awarded a Blanket Purchase Agreement
called VA Enterprise Case Management Solutions (VECMS). This vehicle
provides the VA with easy access to Acumen Solutions' professional
services to implement Salesforce's technology platform for any
department within the VA. In March 2019, VA tasked Acumen Solutions
with developing a Level of Effort for a Minimum Viable Product (MVP)
for the Caregiver Record Management Application project (CARMA) under
the VECMS contract.
The Caregiver program is an important subset of the MISSION Act,
which was passed to improve the VA's ability to deliver health care to
our veterans; and CARMA is a subset of the Caregiver program.
In April 2019, VA awarded Acumen Solutions the CARMA Phase 1
Minimum Viable Product (MVP) Task Order in the amount of $3,841,491.19
to perform implementation and integration services. The scope of the
Phase 1 MVP is to replace the existing system, Caregiver Application
Tool (CAT), used by the Caregiver Support Program (CSP) with an
application built on the Salesforce platform. The new system will have
improved functionality to process and manage CSP applications, allow
for manual determination of eligibility, provide improved program
monitoring and tracking, and capture call records and referrals by the
Caregiver Support Line (CSL).
We recognize the VA's pressing need to develop and build its
Information Technology (IT) systems at less expense and with the
nation's veterans at the center. Acumen Solutions is using the Agile
SCRUM software development methodology to build the CARMA solution,
which enables us to rapidly build Salesforce solutions using
configuration while minimizing custom code. Furthermore, we employ a
User Centered Design (UCD) methodology with close consultation with US
Digital Services (USDS), meaning that we meet with users of the system
to understand their needs and pain points, and then create artifacts
such as prototypes and journey maps, which are then shared with the
configuration team. Our configuration team then works in a two week
sprint, ending with a demonstration of what was built for immediate
feedback. To mitigate risk, we provide VA end-users access to a test
environment with the latest application code, so they can interact with
and test the functionality independently. Each sprint builds on the
previous one until we reach a completed solution. Our methodology
lowers the risk to the VA and to taxpayers by developing pieces of the
overall solution in bite size increments. In addition, we work with the
users throughout to constantly confirm that each stage of development
meets their acceptance criteria.
Our success to date in configuring Salesforce and replacing legacy
systems are a result of collaboration with the VA business office and
its associated product owners, USDS, VA Digital Transformation Center
(DTC), OI&T, the Technology Acquisition Center (TAC), and the
Salesforce Program and Business Architects working at the VA.
Acumen Solutions is proud to partner with the VA and Salesforce to
provide an innovative, effective solution to assist the VA on behalf of
our nation's veterans and their caregivers.
Thank you. I look forward to your questions.